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Inspection report

Date of Inspection: 11, 13 April 2011
Date of Publication: 17 June 2011
Inspection Report published 17 June 2011 PDF

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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

Our judgement

Systems in place did not demonstrate that people receive their medication as prescribed.

User experience

Feedback was received from health and social care professionals as part of this review. Issues were raised about medication practice. Concerns about the care of one person had also been referred to the local authority safeguarding team. This included concerns about medication administration and was still subject to investigation.

Other evidence

During our visit we looked at the medication system in place at the home. We were told that medications are only administered by nursing staff. The majority of medicines required were provided within dosette trays. These were stored securely within medication trolleys held on each unit. Controlled drugs (CD) were also stored under double lock. Stocks of CD’s were checked against the records and found to be accurate.

Medication administration records (MARs) were also looked at. Records had been completed in full. We did note however that times of administration had been identified for ‘when required’ medication (PRN). This was also raised by health care professionals spoken with as part of this review.

We also found errors with the medication for one person, which had been supplied by the clinic. Four weekly blister packs had been provided and had been numbered for each week. One pack had been completed and disposed of. Two further packs had been opened therefore making it difficult to see if the person had been given their tablets or not. As this medication had not been received with the main monthly supply, stocks were difficult to audit. One of the opened packs had medication remaining for 2 mornings however the evening dose had been administered. This meant there would be 2 evenings at the end of the cycle where no medication would be available.

We discussed these concerns with the managers. It was advised that a full audit of the medication system be undertaken to ensure that medicines were being managed safely.