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Temple Grove Care Home Outstanding

All reports

Inspection report

Date of Inspection: 13 January 2014
Date of Publication: 11 April 2014
Inspection Report published 11 April 2014 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 13 January 2014, 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, were accompanied by a pharmacist and were accompanied by a specialist advisor.

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

We had received some concerning information regarding unsafe management of medicines. A pharmacist inspector from CQC checked medicines management in this service.

Appropriate arrangements were not in place in relation to obtaining medicine. We saw that for two people medicines were marked ‘out of stock’ and not administered. When asked, the manager and a nurse told us separately that newly prescribed medicine mid cycle were identified as running out of stock as they had not been added to the medicine dosage system (MDS) system. The supply of medicine was received in a four week cycle at a time in an MDS format. This was a format where medicines were prepared and labelled to be taken for each day for each time in a separate compartment. We were told that one person took responsibility for ordering medicines and because this ‘out of stock’ issue had been identified, the service was going to move to a different supplier who had pledged to give a quicker service relating to receiving newly prescribed medicine in MDS format. This meant that medicines were not received in a timely fashion for continuity of prescribed treatment.

Medicines were not kept safely. There were three medicine storage rooms and four locked trolleys. There was a lockable medicines storage fridge. Fridge temperatures were monitored and recorded daily and there was an air conditioning unit in the main medicine storage room to maintain a safe temperature. We found that one person managed their own medicines and had been provided with a lockable cupboard to store their own medicines in.

There is a legal requirement to store controlled drugs in a cupboard that complies with the Misuse of Drugs (Safe Custody) Regulation 1973 and its amendments. However we found that, although the controlled drugs (CD) were kept in a locked room, the cupboard was not attached to the wall. This meant that CDs were not stored securely.

We found there were two CD cupboards and two CD registers. One cupboard had been named ‘JIC’ which indicated ‘just in case’ cupboard. We found that medicines kept in this cupboard had belonged to people who had died. There was no system to organise the two cupboards and records were difficult to check. We found one discrepancy in the records which staff were told about. This meant that medicines were not being stored safely.

We found that medicines removed from stock for disposal were locked within this room. We saw oxygen cylinders in rooms but these did not have signs to indicate that this area was a fire risk. This meant that medicines were not stored to protect people from harm associated with unsafe storage of medicines.

Appropriate arrangements were in place in relation to the recording of medicine. We looked at all the medicine administration record (MAR) charts for the current cycle. There were some gaps in records where we expected to find a signature for medicines that had been administered. An external pharmacist had recently completed an audit at this service and had made a number of recommendations. We saw an email which informed nursing staff of good practice suggestions in advance of the full medication audit. We were told that audits of medication records had taken place but had slipped recently. The last audit we were shown was from 16 November 2013.

Medicines were safely administered. We watched two nurses separately give medicines to people. The nurses used a caring manner and each person was given their medicines individually. We saw that people were asked if they wanted to take any pain relief medication. This meant people received their medicines in a safe and person centred way.

Several people were prescribed medicine to be taken only if needed. These did not have individual guidance documents for staff on how to manage these medicines. This meant that these medicines may not be given in a consistent way. Staff told us that this would be completed as the care plans were currently being updated. We saw evidence that ca