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Stretton Nursing Home Requires improvement

All reports

Inspection report

Date of Inspection: 19 March 2013
Date of Publication: 17 April 2013
Inspection Report published 17 April 2013 PDF | 77.51 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 19 March 2013, 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 carers and / or family members and talked with staff.

Our judgement

People were not always 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 had not planned to look at the home’s systems for managing medicines. However, we found some issues which concerned us.

We saw that one person had some prescribed skin creams in their bedroom. The care records included instructions for staff about how and where to apply the creams. The instructions did not include all the creams in the person’s bedroom. We saw that there were two tubes of cream, which had both been opened and used. One of these creams had not been prescribed for the person. We asked staff about this and they could not explain why it was in the person’s bedroom.

We tried to check the records of when and where creams had been applied to people. We could not find any charts so we asked staff how they recorded this. They told us that they wrote on the ‘skin integrity’ charts whenever they applied a cream or ointment. These charts were not a complete record. For example, one person had been prescribed a steroid cream. There was no evidence on the ‘skin integrity’ chart that this had been applied. Staff told us that they had applied this cream twice a day. Therefore the records were not accurate.

Another person had been prescribed an antibacterial cream. The instructions stated “back of thighs”, but the diagram which was with the instructions showed the hip area as the site for application. The ‘skin integrity’ chart stated, “cream applied to both legs and feet”. Therefore there was evidence that staff were not following the prescribing doctor’s instructions.

One person had been prescribed a medicine for alleviating anxiety. The care plan stated, “as a last resort and for prolonged panic attacks only due to its addictive nature”. The Medication Administration Record (MAR) chart had a post-it note attached which stated, “only to be given for a prolonged panic attack”. There was no further information for staff. It is important that staff have clear information about when to use medicines which have been prescribed on an 'as required' basis.

We saw that some information including the names and dosages of medicines had been handwritten onto the MAR charts. Some of these entries had not been signed by the person who wrote them. Other entries had not been countersigned to ensure accuracy. It is important that all handwritten entries on MAR charts are signed by two people so as to reduce the risk of inaccurate information.