Morden College personal care service was rated Requires Improvement overall following breaches of Regulation 12 (medicines management) and Regulation 17 (governance), driven by unsafe medicines administration practices and ineffective quality monitoring systems. Strengths included a safe staffing model, positive service culture, good safeguarding practices, and effective infection control.
Concerns (8)
criticalMedication management: “Staff did not always follow best practice guidance...no body maps to guide staff on the administration of these medicines and no medicines administration records (MAR) to confirm administration.”
criticalGovernance: “There were no recorded medicines audits to ensure people received their medicines as prescribed. We found a possible gap in a medicines record which had not been identified.”
moderateMedication management: “Not all staff had completed a medicines competency assessment to ensure training was embedded and that they had the necessary skills to administer medicines.”
moderateGovernance: “Daily support notes staff made as a record of care were not checked for any issues or concerns. Spot checks were completed but these were not recorded.”
moderateRecord keeping: “Some MAR's were handwritten by staff due to communication problems with a pharmacy. However, there was no check made that the handwritten MAR corresponded accurately with the prescription.”
moderateLeadership: “There were some gaps in the manager's awareness of their responsibilities and role. For example, in relation to their awareness of the duty of candour regulation.”
moderateCare planning: “Risk assessments had not been recently reviewed. The manager showed us their improvement plan which had identified this issue and a full review of risk assessments was underway.”
minorComplaints handling: “The complaints policy did not explain all the options where to take a complaint externally if someone was not happy with the outcome of a complaint.”
Strengths
· People felt safe using the service and staff knew how to recognise and report concerns or abuse.
· There were enough suitably skilled staff to meet people's needs with robust recruitment procedures in place.
· Staff completed safeguarding adults training and understood signs of abuse and reporting responsibilities.
· Effective infection prevention and control measures were in place with adequate PPE access.
· There was a positive, open and empowering culture with people fully involved and consulted about their care.
Quality-Statement breakdown (9)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
well-led: Continuous learning and improving careRequires improvement
well-led: Managers and staff being clear about their roles and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: Engaging and involving people using the service, the public and staffGood