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Bricklehampton Hall Requires improvement

All reports

Inspection report

Date of Inspection: 6, 9 December 2013
Date of Publication: 11 January 2014
Inspection Report published 11 January 2014 PDF | 82.19 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 6 December 2013 and 9 December 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

People were not always protected against the risks associated with medicines because the provider had not fully made appropriate arrangements in place to manage medicines.

Reasons for our judgement

As part of this inspection we assessed the management of people’s medicines. We found that improvements were needed.

People’s medicines were stored within one of three trolleys. We spent time with the registered manager and nurses and looked at the records maintained and some people’s medicines. We were informed that during the day time two nurses were on duty. We saw occasions when both nurses were administering medicines.

We saw that each person’s medicine record had a front sheet which included a photograph and a description of how people took their medicines. For example ‘on a spoon’ ‘one by one’ and ‘with water’.

We found gaps in the Medication Administration Record (MAR) sheets for some people who used the service. These gaps meant that nurses had not signed to show that they had administered people’s medicines. We found on people’s MAR sheets that a nurse had initially signed that medicines were taken and then signed to say they were refused.

Nurses had used a code ‘O’ to show why medicines had not been taken. This code meant ‘other’ and required an explanation. No explanation had been recorded. This meant that we were not always able to see why medicines were not given as prescribed. On other occasions we saw that nurses had used an incorrect code. For example, nurses had used the code ‘A’ for asleep. On the MAR sheets it showed that asleep needed to be recorded with an ‘S’.

We found that the numbers of medicines held at the home did not always match the number recorded. For example we found that occasions where people had few tablets left than the records showed. The nurse on duty was not able to account for the shortfall found. The registered manager agreed that we found occasions where it appeared that people had not received their medicines as prescribed. No explanation for our findings could be offered.

We saw a MAR sheet stated ‘One to be taken on alternative days’. The MAR sheet showed that this medicine had been administered seven times over a period of eight days. We asked to see the remaining stock of this medicine but none could be found. We were told that some medicines were used communally due to storage difficulties. This meant that a medicine stock check could not be carried out to ensure that people had received their medicines as prescribed.

Where nurses had recorded the administration of a medicine we were unable to establish whether the correct dose had been given. We saw that nurses had at times recorded administration of the medicine in a different place. This meant that nurses had recorded medicines administered in different places.

We were told that if care staff applied creams to people the application would be written in their personal profile (a written record maintained by staff). We found inconsistency in the records and what staff reported to the nurse on duty. For example, we saw that some creams were signed as applied while others were not. We were shown a cream from one person’s bedroom

The name on the printed prescription label had been crossed out and another name written in its place. This meant that this person had received cream prescribed for someone else.

We found eye drops prescribed for one person which had been opened. They did not have a date of opening recorded. Therefore the registered manager was unable to tell us when these needed to be discarded. These drops were removed immediately to ensure the welfare of the person concerned.