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Archived: Choice Healthcare - Barnsley

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Inspection report

Date of Inspection: 5, 11 February 2014
Date of Publication: 15 March 2014
Inspection Report published 15 March 2014 PDF | 91.6 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 5 February 2014 and 11 February 2014, talked with people who use the service and talked with staff. We talked with other authorities.

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

We asked people about any assistance they required with medication from care workers. Comments included, “They write everything down when we take our medication”, “I recently had some extra medication to take and they saw to that no problems”, “She [care worker] brings me my tablets over, counts them and I do too and agree with the number. Got a sheet of paper they fill in when I’ve taken them” and “I get them ready myself on my tray and they make sure I have them all.” No one we spoke with had any concerns regarding medication.

The service had a medication policy which the manager told us was currently being reviewed. We saw pro forma of a new ‘medication record sheet’ which we were told would be implemented to improve consistency across the service.

Care files we looked at, where applicable, contained details of the person’s medication, a medication permission form in some instances and a medication risk assessment form where this was applicable. The provider may find it useful to note that the risk assessments were not always completed correctly and did not always reflect the person’s current circumstances. For example, risk assessments recorded that people did not take medication when in fact they did.

We spoke with four care workers who told us about their role in assisting with medication and completing relevant documentation. We saw a training matrix which showed where people had received medication training and evidence in staff files we viewed to show training had been completed. It was not clear whether, and how often, this training was refreshed. The provider may find it useful to note that no competency assessments or formal observations were undertaken whereby staff would be observed handling medication to ensure they were proficient. Staff told us they would contact the office if they were unsure about anything relating to medication.

We looked at MAR (Medication Administration Record) charts for three people who used the service. These were completed within the person’s home and we were told that they were returned each month to the office for filing. At one person’s home, we saw the current months chart and saw that information had been recorded and signed where required.

At the office, one person’s previous MAR charts we requested could not be located. We were only able to see their records from July 2013, even though the person had still been taking medication since this date. The provider may find it useful to note that we saw several gaps in the chart for this month where nothing had been recorded. No code had been completed to account for the omission, for example if the person had refused their medication. It was not evident that these omissions had been investigated.

There was no formal procedure in place for completed returned MAR charts to be checked and audited. As such, any errors or omissions, unless reported at the time they were identified, could not be investigated. This meant any recurring trends such as repeated omissions or incorrect recordings were not being addressed and actions put in place to rectify these.