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Barnfield Manor Care Home Good

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Inspection report

Date of Inspection: 22 October 2012
Date of Publication: 5 December 2012
Inspection Report published 5 December 2012 PDF | 85.97 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 22 October 2012, observed how people were being cared for and talked with carers and / or family members. We 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 protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for obtaining, recording, handling and safe administration of medicines

Reasons for our judgement

We visited the home in July 2012 and found medicines were not being managed safely. After our visit we asked the provider to tell us how they were going to make sure medicines management improved and become compliant with the standard.

At this visit on 22 October 2012 we found that some improvements had been made but overall people were still not protected against the risks associated with the unsafe use and management of medicines.

We looked at medication and records about medication for eight people. We found concerns about the safe handling of medicines for all eight people.

We found that improvements had been made in the storage of medicines, but not all of the arrangements were appropriate to ensure the safe storage of medicines. We saw that medicines were locked away in suitable cabinets and trolleys. However, as at the last inspection, we found that that creams were stored in people's bedrooms without any assessments that it was safe to do so. We saw that a date had been written on the creams to show when they had been opened, however we found the creams were still sealed.

We found that appropriate arrangements were not in place in relation to obtaining medicine. Two of the eight people whose medicines we looked at, had "run out" of one or more of their prescribed medicine for up to seven days. Nurses also told us that a further four people did not have a supply of their prescribed creams and medicines available on the day of the inspection. If people do not have medication available to be administered as prescribed, their health may be placed at risk.

We found that medicines were not always given to people appropriately. Staff failed to follow the directions of the prescribers and the manufacturers accurately so some people did not have their medicines, including creams, as prescribed. We saw that people who were prescribed medicines which must be given with food were given them at the same time as medicines which should have been given 30 to 60 minutes before food. If people are not given their medicines as prescribed their health may be at risk.

We found that improvements had been made in the information available for staff to guide them as to where to apply prescribed creams. We also found that there was now some information recorded to guide staff how to give medicines which were prescribed to be given "as required" or as a variable dose. However this information was still not available for all medicines prescribed in this way. It is important that this information is recorded to ensure people are given their medicines safely and consistently.

Appropriate arrangements were not in place in relation to the recording of medicine. We looked at the records about medicines and found there were missed signatures, gaps, on the medicines administration charts so it was not possible to tell whether medicines had been administered. It was not possible to account for all medicines because the records about the quantity of medicines in the home were not always accurate. When there was a choice of dose of medication to administer, the records did not always show the exact dose given. We saw that sometimes medicines had been given but staff had failed to sign the records appropriately. When the quantity of medicines in the home was compared with the records it showed that medicines had been signed for but had not been given. It is important to keep accurate records to ensure people’s health and welfare are protected.