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Archived: Chaseley Bungalows

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Inspection report

Date of Inspection: 13, 21 August 2014
Date of Publication: 18 September 2014
Inspection Report published 18 September 2014 PDF | 107.7 KB

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 13 August 2014 and 21 August 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, 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, talked with commissioners of services and talked with other authorities.

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

An agency registered nurse who told us that they had worked in the home 4-5 times was in charge of the medicines on the day of this inspection visit. We asked to see how the home had assessed their competencies and understanding of this role in the home. We were shown a checklist that had been completed in conjunction with a care worker in the home. This recorded that they were aware of the home’s medication policies and procedures. However there was no evidence that their competency or understanding had been checked in any way. The provider had not made arrangements to ensure that staff handling medicines had the competency and skills needed.

We spoke with four people regarding medication and three people were able to tell us about their medicines. Two people told us that they received their prescribed medicine when they needed them and as prescribed. They said, “Yes I get my medicines as I should, sometimes they are a little late but mostly on time,” and “I know what I should be getting and when and If get them correctly.” One person told us that there had been supply issues in the past which meant they did not always get their prescribed medicines. They went on to tell us that pain killers had been dispensed to them that morning at the wrong time. They were able to decline the medicine which was later administered at the correct time.

We looked at the corresponding records and found that this mishandling of medicines had occurred and related to a controlled drug. This showed us that prescribed medicines were not always available and medicines were not always handled safely.

We saw that suitable storage facilities for controlled drugs were provided. We checked the controlled drugs cupboards against the corresponding register and found that the record was accurate. There was a system in place to check the register on a regular basis to ensure it was accurate. We found that one entry in the controlled drug register for the morning of the 13 August 2014 recorded that a drug was administered at 06.00. The medicine administration record (MAR) chart recorded that it was administered at 08.00. The person receiving the drug confirmed that it was actually administered at 08.00, although it had been presented to them at 05.00 in the morning. The registered nurse in charge of medicines confirmed that she and the registered nurse who had worked the night shift had administered the drug at 08.00. The controlled drug register had not been signed by the registered nurse working the day. This meant that legal register had not been completed accurately and the home’s procedures on administering controlled drugs had not been followed.

The fridge used for storing any medicines requiring refrigeration was checked. We found that the temperature was being monitored on a daily basis and was being recorded. This record identified that from the beginning of June 2014 the fridge temperature exceeded six degrees centigrade. It should not exceed five degrees centigrade to ensure a safe temperature. The registered nurse in charge of the home told us that a new fridge had been ordered. This meant that any medicines that required refrigeration could not be stored safely in the home.

Each person had an individual cabinet in their accommodation to store their medicines, apart from two people who had some of their medicines stored centrally in cabinets in the office. All cabinets were locked and only accessed by a registered nurse. We found one cabinet had a broken lock and although this had been reported three days previously it had not been replaced or repaired. This meant that medicines were not being stored safely. This was identified to the deputy manager who arranged for another cabinet to be provided on the morning of the inspection visit.

We noted that the central office area where the controlled drugs were stored was having its temperature monitored. We were advised that this system was being rolled out to all areas to ensure medicines wer