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Inspection report

Date of Inspection: 7 January 2013
Date of Publication: 9 February 2013
Inspection Report published 9 February 2013 PDF

People should be given the medicines they need when they need them, and in a safe way (outcome 9)

Enforcement action taken

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 7 January 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.

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

Medication was not always safely stored or administered. Accurate records of administration were not always maintained and people were not protected against the risks associated with the unsafe use and management of medicines.

Reasons for our judgement

We spoke with people using the services but their feedback did not relate to this standard.

Arrangements were in place in relation to the recording of medicine. Clear records were kept of all medicines received into the home, and any unused medicines disposed of.

We looked at three people’s Medication Administration Records (MAR). These records showed that medicines were not always administered as prescribed. For example, two of the three people’s medicine records we reviewed had gaps on the charts. At times reasons for not giving people their medicines were recorded. However, this was not consistent and there were gaps in the charts without reasons for the medicine not being administered. For example, if a person refused medicine, the MAR had a code which was to be used to record the person’s refusal.

Medicines were, at times, kept safely when not in use and were stored securely for the protection of people who used the service. All medicines were stored in locked cupboards and medicine trolleys within a clinical room when not being used. We observed elements of two medicine rounds. Medicine rounds were undertaken by one member of staff. During the medicine round, we observed a member of staff leave a number of compliance aids (system from which prescribed medication was administered, such as a blister pack or dosette box) full with prescribed medication on the top of the drug trolley in a corridor. The member of staff left the drug trolley unsecured and unattended with the medicine on top in the corridor and went to a person’s room to administer them their medicine.

There was a separate lockable cupboard to store controlled drugs. Controlled drugs are some prescription medicines which contain drugs that are controlled under the Misuse of Drugs legislation. Keys to access the drug trolley and controlled drugs were kept on the person of the staff member responsible for administering medicine. However, we observed the member of staff lock the medicine in the drug trolley and then put the keys to the trolley in a low level window in the corridor whilst they went to another person’s room to administer their medicine. This meant that people, staff and other visitors had access to the prescribed medicine and other medicine such as homely remedies left within the trolley. Current guidelines from the Royal Pharmaceutical Society of Great Britain published in 2007 state that states that key security is an important part of medicines security therefore only authorised members of staff should have access to them.

Medicines requiring cool storage were stored in an appropriate fridge. The maximum and minimum temperature of the refrigerator was recorded, but there were a number of gaps in the daily records where no temperature had been recorded.

The provider had a policy for medicines management which had been reviewed in July 2012. The policy stated that maximum and minimum temperatures were to be taken daily. The policy also stated “Temperatures 8 degrees or higher must be reported to maintenance immediately for corrective action and this must be documented.” The policy did not define what action should be taken with regards to the medicine in the fridge. The failure to store medicines correctly can reduce their effectiveness and cause medicine to fail.

Medicines were not always administered safely because people did not always receive their medicine at the time it had been prescribed for. We observed a member of staff administer a medicine for diabetes to a person over two hours after the time it had been prescribed for. It is important that people receive their medicine at the time prescribed for and that they receive it at the same time each day.

No one living in the home was looking after or taking any of their own medicines. Staff had access to copies of the home's medicines handling policies for guidance.