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Archived: Rydan Lodge Residential Home

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Inspection report

Date of Inspection: 17, 18, 22 October 2013
Date of Publication: 15 March 2014
Inspection Report published 15 March 2014 PDF | 118.17 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 17 October 2013, 18 October 2013 and 22 October 2013, 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 sent to us by commissioners of services and reviewed information sent to us by local groups of people in the community or voluntary sector. We talked with commissioners of services and talked with other authorities.

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.

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

Prior to the inspection we had received a concern about a lack of training and competency of care workers with the safe management of medicines.

We spoke with a night care worker, who had completed a medication management workbook. They told us they would not be considered safe to administer medication until their practice had been observed several times and knowledge tested. We saw a care worker give a person living at the home their morning medication. They explained to them they were giving them medication and stayed with them until they had taken it.

We saw that the home had a homely remedies policy. This detailed ‘over the counter’ medication that could be given to people living at the home without prescription. However, this policy had expired in August 2011.

We looked at the medication administration records (MAR) for the people living at the home. We saw that there were no photographs of the people living at the home on the records. This meant it would be difficult for a person who did not know the people living at the home well, such as new staff or agency workers, to check their identity.

We saw that medication was supplied to the home in a series of colour coded blister packs by the supplying pharmacist. Where a new month’s blister packs were being supplied to the home we saw that care workers were not recording the receipt of medication individually on the MAR chart or elsewhere. We also saw in the medication administration records that some people had been prescribed medication with a variable prescription, i.e. one or two tablets to be taken. We saw that staff completing the record did not include how many tablets had been given. This meant it was not possible to do a full audit check on the balance of medication at the home.

We looked at the controlled medication stock kept by the home. The controlled medication was not all being stored in the lockable trolley. Some had been removed and was being kept in the provider’s office pending return to the pharmacy. We found the balance of this balanced with the stock amount listed in the controlled drugs book.

However, elsewhere in the book we found records telling us that other controlled medication was still in stock for people no longer in the home. The provider told us this had been returned to the pharmacy or had moved with the person to a new home. However there was no record of this, or copies of receipts or returns from the pharmacist available. This meant that there was no complete recorded audit trail for this medication.

We looked at the records for one person staying at the home on a respite stay. We saw that the person had been prescribed two types of painkilling tablets to be taken if needed. We spoke with a senior care worker who told us that the person had been complaining of pain recently, and we saw that medication had been given to help with this. The care worker told us that they understood that the two types of medication were not to be given together, and that this was stated on the packet of one medication. We saw this was not clearly explained either on the MAR chart or in the person’s care plan. We checked the MAR and found that on one occasion the care worker administering the medication had signed to say they had administered both medications at the same time on the same day. This put the person at risk.

Medication was kept in a locked trolley in the staff room area. However we found some medication waiting to be returned to the pharmacy was left unsecured in an open box in this area.

Two care workers at Rydan lodge were undertaking level two on line training for the safe handling of medications. Staff files showed that four care workers at the home did not have up to date training. We made the registered manager aware of this.

We asked to see MAR records at the domiciliary care service because of specific concerns that had been raised with us. We found that in a completed MAR sheet for one person who had previously us