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Archived: Haddon Court Nursing Home Requires improvement

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Inspection report

Date of Inspection: 23 June 2014
Date of Publication: 22 July 2014
Inspection Report published 22 July 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 23 June 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and reviewed information sent to us by commissioners of services. We reviewed information sent to us by other authorities and reviewed information sent to us by local groups of people in the community or voluntary sector.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

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

We looked at the storage of medicines, three people’s medicine administration records (MAR) charts in detail, including their care plans and some other additional MAR charts and documents.

We observed two nurses during the evening medicines round. They administered medicines and this was done patiently with regard to people’s dignity and personal choice. Both nurses were fully aware of ensuring any sedative medicines were administered when people were in bed and they had safely followed the homes policy in that practice. However, we saw keys were consistently left in the lock of one drug trolley and the other drug trolley had a open container fixed to it containing several inhalers.

We saw some medicine cupboards were open and left unsecure without keys available to securely lock them, which did not follow the homes policy in practice for safely storing medicines This demonstrated that the procedures used were not always safe and did not follow best practice.

Nurses did not always follow the homes policy in practice for ordering prescriptions, recording keeping, and filing of MAR charts including drug audit checks of medicines stored in the home. We noted unfiled MAR charts and several prescriptions and medicines loosely left untidy in one of the clinic rooms.

We observed that some people living in the service also had a preferred name although this was not recorded on the MAR chart. This meant that there was an unnecessary risk of wrongly administering medicines to another person living in the service.

We noted that some people living in the service had allergies and this was not recorded on their MAR charts to alert staff as well as the local pharmacist supplying medicines to the home. This meant that there was an unnecessary risk of medicines dispensed or administered which may have detrimental effects to people living in the service.

We found that the quantities of medicines carried forward to a new recording period were not always completed and so it was difficult to account for all medicines and nutritional supplements.

We found some medicines had been delivered by the supplying pharmacy but the delivery packs were left unopened. This meant that we were not always assured that people were given their medicines and ‘creams’ as prescribed in a timely manner.

We noted the temperature readings in all the clinic rooms’ were well above the maximum temperature range to store medicines. Medicines may not be effective as they were not appropriately stored as directed by the manufacturers.

We found some people living in the service were self-administering tablets, ‘creams’ and inhalers, and these were not securely kept in their rooms. Although there were some recorded risk assessments in place, care workers had not monitored the storage arrangements properly. This meant there was a risk that medicines were not always safely handled.

We found that where people were given medicines on a ‘when required’ basis for example, for pain relief or to control a person’s challenging behaviour , there was insufficient details and guidance for staff on the circumstances these medicines were to be used. This meant people may not have been given medicines to meet their needs to ensure safe and consistent use.