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Inspection report

Date of Inspection: 13 November 2013
Date of Publication: 11 December 2013
Inspection Report published 11 December 2013 PDF | 78.78 KB

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

Meeting 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 13 November 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

Reasons for our judgement

During our inspection we saw that medicines were handled appropriately.

Policies and procedures were in place in relation to obtaining, storing, administering, handling and recording medicines. However, the provider might find it useful to note that the policy folder included a large volume of information from different sources and that information did not appear to be contained in one clear format.

We saw that medicines were supplied by an external pharmacy and that arrangements were in place for regular audit of the systems for medicines management within the home. We were told that urgent medicines were delivered on the same day they were requested.

We saw that care plans detailed how people were supported with their medication and that medication administration record (MAR) charts in use were clear and signed. We carried out checks on the medication records of four people who used the service. We saw that all medication records were up to date and accurate, with no gaps seen on the individual recording sheets. We were told that MAR charts were supplied along with the medicines by the local pharmacy and that these were routinely checked by two registered nurses on receipt. We saw that an up to date list of medicines was taken when a person began to use the service.

We saw that medication was stored safely in lockable medication trolleys and a stock cupboard in a locked clinical room. Keys were held securely by the registered nurse on duty. We saw records that demonstrated daily temperature checks were carried out on the room where medicines were stored and the medication fridge.

We saw that controlled drugs were stored safely and that stocks were routinely checked on a weekly basis. The provider might find it useful to note that the system for checking controlled drugs was not part of a routine checking system and as such had not been carried out when regular staff were on leave.

We observed a system in place for the safe disposal of unused or unwanted medication that included the recording of disposal and pharmacy collection.

We saw a system for reporting and recording medication errors, near misses, incidents and adverse events. We were told that when an incident occurred the person using the service, their relatives and General Practitioner were informed. We saw records that included support for workers to learn from incidents that included additional training and supervised practice as required.

We saw records that demonstrated covert administration was only undertaken in line with the Mental Capacity Act 2005. We saw that best interest discussions were held and decisions to administer medicines in this way were made under written instruction from the person's GP and following discussion with their relatives.

We saw a policy that stated people living at Westerleigh were encouraged to self administer their medication, however we were told that no-one was self administering their medication at the time of our visit. We were told that if people wanted to self administer they would be assessed to do so if appropriate, however it was unclear how people who wanted to self administer were identified. The provider might find it useful to note that people were not routinely asked about self administration of medicines on admission to the home and methods for assessing self administration were unclear.