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Heathfield (Horsham) Limited Good

All reports

Inspection report

Date of Inspection: 21 September 2012
Date of Publication: 18 October 2012
Inspection Report published 18 October 2012 PDF

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

Not met this standard

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

Our judgement

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

The provider is not meeting this standard. We judged that this had a minor impact on people using the service and action is needed for this essential standard.

User experience

People told us that they received their medicines at the times they expected them.

One person said,” I rely on staff to make sure I have my tablets. They always make sure I have what I am prescribed. The doctor visits regularly and I see him when I need to.”

Other evidence

We saw that the home had a policy in place for the safe and appropriate administration of medicines. We were told that this policy had been read by staff.

We saw that all prescribed medications, dressings and creams were prescribed for individual use and were recorded on the persons MAR sheet.

We were able to see that medications were stored in locked cupboards and a trolley. We saw that the medicine fridge was locked and that the temperature of the fridge was recorded by staff daily.

We saw that the controlled drugs (CD) were stored in a separate locked cabinet and that a record of medicines was recorded in the CD register. We found a partially completed entry in the register for one person. The amounts of the medicine matched the record but this did not explain the incomplete record. The deputy manager and staff member responsible for medicine management could not fully explain the error.

We saw that each Medication Administration Record (MAR) sheet contained a name and a photograph for all residents. We saw that the MAR sheet was legible however there had been changes to the times medicines were to be given that had not been evidenced with confirmation from the prescribing GP. The deputy manager said these changes had deviated from their agreed practice. They provided us with a letter faxed by the GP for one of the previous changes to an individual’s medicine as an example of the home’s usual practice.

We saw that medicines for one person that were prescribed daily had not been recorded as given. The staff told us this was because the individual did not want to take this medicine. The medicine had not been reviewed with the person’s GP in order to amend the prescription and there was no record of the refusal.

We also saw that ‘when required medicines’ and medicines with a variable dose were not supported with guidelines or administration protocols to ensure a consistent approach from staff.

We saw the training records for all staff responsible for administering medications. We were told that staff were assessed by the manager and passed as competent before being left to administer medications independently.

The manager provided information following our visit to show that they audit the medicine management records monthly however September’s audit had not been undertaken at the time of our inspection. We were shown that the home was last audited by the pharmacist in 2010.