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We are carrying out a review of quality at The Belvedere Private Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.
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Inspection report

Date of Inspection: 7 November 2012
Date of Publication: 24 February 2012
Inspection Report published 24 February 2012 PDF | 94.86 KB

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 November 2012, checked how people were cared for at each stage of their treatment and care and talked with staff.

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

At our inspection on 13 September we found the provider did not have effective arrangements for the handling of medicines, out-of-date medicines were not disposed of in a timely manner. The provider had failed to have in place an appropriate person as the hospital's Controlled Drugs Accountable Officer (AO) which is a regulatory requirement.

Medicines are not handled safely. At our inspection on 07 November 2012 we found that out-of-date medicines were not disposed appropriately in a timely manner. We found medicines in a cupboard in the recovery room, in the medicines refrigerator and in the anaesthetics room that had expired in October 2012, despite there being a record that medicines had been checked for their expiry dates in October 2012.

The provider did not have effective arrangements in place to manage medicines. For example we found strong potassium chloride injection not stored in accordance with Patient Safety Alert 1051 (2002); it was stored on the resuscitation trolleys, instead of in secure storage away from other similar medicines and in one case these drugs were not in a labelled box This increased the risk to this medicine being used in error which could endanger the health of people using the service.

There was a copy of the British National Formulary dated March 2008, therefore there was no up-to-date medicines information for nursing staff to refer to. This lack of up to date information may lead to medicines not being administered in the most appropriate way to people.

The proposed registered manager who we spoke with informed us that they had informed the Department of Health of their intention to become the hospital's Controlled Drugs Accountable Officer. However, the provider had not informed the Care Quality Commission of their appointment, which they are required to do.

The standard operating procedures (SOP), which are the formal written operating procedures, required to be in place for the controlled drugs had been updated and the person named as Accountable Officer was aware of the contents of this document. However, they were not fully aware of their duties under the Safer Management of Controlled Drugs Regulations 2006. For example the person did not know that they had to register with the Care Quality Commission as an Accountable Officer.

The controlled drugs were kept in a locked cabinet and a record book was available to record the usage of the medicines. However, there was no record of the AO's monitoring and auditing of the management and use of controlled drugs by relevant individuals and therefore the safe use of these medicines could not be confirmed.