Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
The risks posed by poor medicines management can result in serious or fatal illness.
Health and social care staff often manage medicines on behalf of people using their services. Providers must promote the safe and effective use of medicines in care homes. This includes prescribing, handling and administering medicines. Failing to do this poses real risks to people who may be vulnerable, including:
- older people
- people with reduced mental capacity, reduced mobility, a sensory impairment
- people who rely on help to take their medicines
Prosecution by CQC
In September 2016, CQC successfully prosecuted a care home provider and a registered manager. Both failed to provide safe care and treatment resulting in avoidable harm.
A 78-year-old man with vascular dementia relied on the provider and registered manager to make sure he received his medicines safely.
Two weeks after moving to the service the man was admitted to hospital and discharged four days later on anticoagulant therapy. He was discharged with an 18-day supply of medicine. The provider and manager failed to order a new prescription after the 18 days. Their systems failed to identify that the medication was missed for between 30 and 33 days.
The man died from a pulmonary thromboembolism and deep vein thrombosis. CQC's investigation uncovered other unsafe medicines practices for this man, including:
- incorrectly transcribing prescriptions
- having only one staff member booking medicines in, when two were required
- gaps in the administration of medicines
- continuing at a higher dose when the dose should have reduced
- poor recording on medicine administration records
In relation to other people using the service the following errors in medicines management were identified:
- omissions in prescribed medicines
- medicines frequently out of stock
- failure to record allergies
- failure to record times and dosages of medicines
The provider was ordered to pay:
- £50,000 fine
- £120 victim surcharge
The registered manager was ordered to pay:
- £665 fine
- £66 victim surcharge.
The provider has taken steps to improve
We inspected the care home in September 2015 and had concerns around safety, effectiveness and leadership of the service. The service was rated as requires improvement for the three key questions about safe, effective and well-led. The provider carried out an internal investigation which identified that senior staff in the home had failed to follow policies and procedures when booking in medicines. Staff were given additional training, which was supported by the clinical commissioning groups. In March 2017 the service was re-rated as good.
What can you do to avoid this happening?
Unfortunately, medicines errors are common, but you can do something to reduce the risk.
Guidance and standards for providers and managers around managing medicines when caring for people in care homes and community settings:
CQC adult social care medicines FAQs (Google Drive)