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Archived: Montrose Good

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Inspection report

Date of Inspection: 2 February 2012
Date of Publication: 23 May 2012
Inspection Report published 23 May 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 who use these services are not protected against the risks associated with the unsafe use and management of medicines. Montrose care home does not have safe, effective arrangements in place for recording, handling and dispensing of medication.

Overall Montrose Care Home was not meeting this essential standard.

User experience

One person told us that drops had been prescribed to be put on a wound and that a care worker had put them into her eyes. We did not see that an incident form or medication error form had been completed. This was discussed with the registered manager and it was not clear that any action had been taken as a result of this error.

During the inspection visit we observed medication given to people with no explanation given by the carer of what the tablets were for or ensuring that the person took the tablets. In one person’s room we saw several medicine pots from previous medication rounds. We also saw one person with antibiotics in a medicine pot on their table.

Other evidence

We reviewed 10 medicine administration records (MAR) charts. There were discrepancies in the documentation on these records. For example we noted that antibiotics on at least two occasions had not been signed for. We also noted that a person was prescribed a drug to be given when required, however it was noted it was given routinely four times a day every day.

A protocol for the administration of ‘when required’ medication was not available. We did not see evidence of regular audit of medications or MAR charts.

We saw a person self-medicating with a spray under the tongue which was kept in their room. This person told us that staff were not alerted when the spray was used. The MAR chart was reviewed for this person and it was found that this medication spray was not prescribed on the MAR chart.

On one MAR chart it was noted that a prescription for antibiotics was hand-written, not dated or signed.

The training matrix did not identify that staff had received training in medication administration. However we saw in two staff files that they had attended medication awareness training.