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Heathfield (Horsham) Limited Good

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Inspection report

Date of Inspection: 18 April 2013
Date of Publication: 24 May 2013
Inspection Report published 24 May 2013 PDF

People should be given the medicines they need when they need them, and in a safe way (outcome 9)

Enforcement action taken

We checked that people who use this service

  • Will have their medicines at the times they need them, and in a safe way.
  • Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 18 April 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members, talked with staff and reviewed information given to us by the provider.

Our judgement

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Reasons for our judgement

When we inspected this service in September 2012 a compliance action was set because people were not protected against the risks associated with medicines. At this inspection we found evidence of continued non compliance.

A 'monitored dosage' (blister packed) system was in use. Medicines were secured in a locked trolley which was stored in a locked storeroom. The manager told us the storeroom temperature was not monitored or recorded. This meant the provider could not be certain that medicines were stored at the recommended temperature to retain their stability.

A medicines fridge was available for medicines requiring cold storage. Daily records were maintained to demonstrate the fridge temperature was within recommended limits.

The facility for storing controlled drugs (CD) was satisfactory and complied with legislation. We checked the number of controlled drugs (CD) stored in the home and found that receipt and administration of controlled drugs were not always accurately recorded in the home’s CD register.

We audited the medicines of four people by comparing the quantity in stock against the signatures on the medicine administration records (MAR). We found three recording errors which meant it could not be confirmed that medicines had been administered correctly.

The manager told us that there was no system in place to monitor the number of medicines ‘in stock’ in the home. Medicines were delivered to the home each month and their receipt was recorded on people’s individual MAR sheets. A record of unused, ‘carried forward’ medicines was not kept. This meant the provider did not have an accurate audit trail to check on the receipt, administration and disposal of medicines.

We saw no evidence of competency checks for staff administering medicines. The staff we spoke with told us they undertake training in the safe administration of medicines, but there was no evidence that staff were observed administering medicines to check they were competent.