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Archived: Dovecott Care Home

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Inspection report

Date of Inspection: 3, 13 June 2013
Date of Publication: 2 August 2013
Inspection Report published 02 August 2013 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 3 June 2013 and 13 June 2013, observed how people were being cared for and talked with carers and / or family members. We talked with staff, took advice from our pharmacist, reviewed information sent to us by other regulators or the Department of Health and talked with commissioners of services. We talked with other regulators or the Department of Health and took advice from our specialist advisors.

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. This was because staff were not always following policies and procedures, records were not accurately maintained and people had not always received their medicines as prescribed.

Reasons for our judgement

We did not plan to look at this outcome during this inspection. However during the course of the inspection we found that people may not have received their medicines as prescribed.

A policy and procedure for safe handling of medicines was in place. Dates were recorded to indicate when reviews of the policy had been undertaken. We found that staff had not been following the policy and procedure in that they had not used the codes to record the reason for non-administration of medicines and had not followed the procedures for recording "as required" medicines.

We found that very basic checks of the medicines records were completed monthly. These recorded that some issues such as gaps in “as required” medicine records had been identified. However these checks were not robust as theyhad not identified that staff had not followed the policies and procedures or that people may not have had their medicines as prescribed.

On the first day of our inspection in June we found one person was prescribed medicine twice per day “as required” to manage behaviours that may challenge the service. We found this medicine had been given every morning and on one occasion had been given three times in one day. Whilst the persons presenting mood and behaviour were recorded on each shift these records did not identify a pattern of behaviour that would indicate that this medicine was required every morning. On the day where the medicine was given three times the records stated that the person had been settled all day. This means that the medicine had not been given as prescribed and that the persons presenting behaviour had not been taken into account in the decision to administer the medicine. We referred this to the local safeguarding team.

On the second day of our visit we were shown that new care plans and instructions to staff to record the reasons for administration of the medicine had been implemented. However we also found the prescription had been altered by the manager in the medicines administration record (MAR) to support the daily administration of the medicine in the morning. There was no evidence that this change had been discussed and agreed with the GP or other health professional. This meant that the medicine was still not being given as prescribed.

We looked at a random selection of MARs dated 11 February 2013 to 2 June 2013.

We found that one person was prescribed medicine for their blood pressure to be taken twice daily. The MAR indicated they may have been given this three times per day on at least two occasions during one week in February 2013. The records of signatures to show administration of the medicines were not clearly maintained and some signatures had been crossed out with no reason for this recorded.

We also found a number of gaps in records where signatures had not been entered to evidence if the medicine had been administered or not. Codes to show where medicines had not been administered had not been used on any of the records seen. This meant there was no clear record of the medicines people had taken and there was no clear audit trail of medicines in the home.

We found that one person had missed the administration of their controlled drug, a fentanyl patch, on one occasion. This should have been changed every 72 hours for pain control. We found that care records indicated the person had felt sick and dizzy during this period of time but there were no concerns of any pain or agitation recorded.

Hand transcribed records were not always signed and there was no evidence that the records had been checked for accuracy. This meant that there was an increased risk of error in recording prescription details which may lead to people not having medicines as prescribed.

There was no evidence that regular checks of medicines in relation to expiry dates were completed and we found one medicine in the controlled drug cabinet with an expiry date of May 2013. The manager informed us that she had contacted the dist