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 May 2018, CQC successfully fined a care home provider and a registered manager. Both failed to provide safe care and treatment resulting in avoidable harm.
A 79-year-old lady who was frail and vulnerable moved into the service for a period of respite care because she was struggling to look after herself at home. The lady relied on the provider and registered manager to make sure she received her medicines safely.
The lady arrived at the home with a bag of medicines including pain killers. The same day, the GP surgery provided a list of medicines prescribed to the lady. The provider and registered manager failed to assess the lady’s needs and failed to check what current medicines the lady should be taking. Their systems failed to identify that current prescribed medicines had been incorrectly transcribed onto the medicine administration record. They failed to check that staff followed their medicines policy. Their systems failed to identify that too many pain killers had been written on the medicine administration record.
Five days after moving to the home for respite care the lady died of an overdose of pain killers.
CQC's investigation uncovered unsafe medicines practices for this lady, including:
- no assessment carried out of the lady’s needs including her medication needs
- no care plan written about what care and support was needed
- failure to check what the lady was currently prescribed
- incorrectly transcribing medicines to the medicine administration record
- incorrectly recording medicine to be taken regularly rather than PRN (as and when required)
- failure to record variable doses administered (one or two tablets)
- pain killers being given when the lady was not in pain
- having only one staff member booking medicines in, when two were required
- lack of oversight and checks of the medicines being given to the lady
The provider was ordered to pay:
- £4,000 fine
The registered manager was ordered to pay:
- £4,000 fine
The provider has taken steps to improve
We inspected the care home in July 2018 and had concerns around safety and leadership of the service. The service was rated as requires improvement for the two key questions about safe and well-led. Staff were given additional training, which was supported by the clinical commissioning group. The provider strengthened governance and oversight. Following an inspection in January 2019 the service was re-rated as good. At an inspection in September 2019 the service remained rated 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:
Learning from safety incidents
Each of these pages 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.
Read the NICE information
NICE Managing medicines in care homes
NICE Managing medicines in community settings
NICE medicines management in care homes quality standard
See also
CQC adult social care medicines FAQs (Google Drive)