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Archived: Hazelmere

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 5, 15, 16 September 2014
Date of Publication: 30 October 2014
Inspection Report published 30 October 2014 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 5 September 2014, 15 September 2014 and 16 September 2014, talked with people who use the service and talked with staff. We reviewed information given to us by the provider, were accompanied by a pharmacist, talked with commissioners of services and talked with other authorities.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

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.

Reasons for our judgement

Two people we spoke with told us that changes to their medicines needs were not promptly addressed. This meant that people might not receive the support they need to take their medicines safely.

Medicines were administered by suitably trained support staff. Most people we spoke with felt that support workers provided them with the help they needed with managing their medicines. We saw that care was taken to ensure that any special label instructions such as ‘before food’ were followed when administering medicines. Assessments were in place where people were prescribed controlled drugs for pain-relief to ensure these were given at the right times.

However, some people we spoke with told us that they did not receive their medication correctly because calls were sometimes missed, or late. Additionally, one person told us that they did not always have their prescribed creams applied because they, “don’t like strangers (agency staff)” applying them. We found that there were occasional 'gaps' in the medicines administration records that meant it was not possible to tell whether medicines had been administered correctly.

The service had a protocol for reporting medicines incidents but we found that this was inconsistently used. For example, failure to administer medicines due to a lack of stock was not always reported. This meant not all incidents were investigated to try and reduce the risk of reoccurrence.