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Archived: Bevan House

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Inspection report

Date of Inspection: 14 October 2011
Date of Publication: 14 November 2011
Inspection Report published 14 November 2011 PDF | 87.24 KB

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

Meeting 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 reviewed all the information we hold about this provider, carried out a visit on 14/10/2011, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

The registered provider is now compliant with Regulation 13 and medicines are managed safely; however improvements have been suggested under this outcome as staff has no guidance on the use of covert administration.

User experience

On this occasion we did not speak to people about this outcome area.

Other evidence

At our last review of compliance we found that people could not be sure that their medicines were properly managed because the registered provider had not taken steps to make sure that medicines were managed safely, securely and appropriately.

People who use the service were being placed at risk of abuse and harm because some of the staff giving medicines had not had the appropriate training with regards to giving, storing and recording of medicines.

There were no clear guidelines for staff to follow for medicines given to people for agitation or challenging behaviour. This information was passed onto Croydon Social Services Safeguarding team and a strategy meeting involving people who use the services care managers was held.

Our pharmacist inspector visited the home on the 22 August 2011 to assess compliance with Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. They found that the homes arrangements for the recording, handling, using, safe administration and disposal of medicines did not comply with Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

They concluded that the service did not fully protect people against the risks associated with the unsafe use and management of medication by means of the making of the appropriate arrangements for the receipt, recording, administration and disposal of medicines.

A warning letter was served to the registered provider on the 06 September 2011 requiring them to become compliant with regulation 13 of the Health and Social Care Act 2008 by the 23 of September 2011.

When we assessed medicines management at this visit, we found the service had addressed the specific issues mentioned in the warning notice, and that the management of medicines had improved. Staff were now responsible for giving medicines to only one person, as the second person at the service was able to manage their own medicines. We saw that prescribed medicines were available, were stored safely and had been given when needed. Records of medicines given were now completed accurately therefore the service had complied with the warning notice.

During the inspection of medicines records and care plans, we observed issues related to other outcomes, see Outcomes 4 and 14.

We saw from care records that staff were giving one person one of their medicines mixed with a hot drink or cereal. We discussed this with the manager and area manager, but they were unable to explain the reasons for this and did not know whether it was being disguised in food or drink because the person had refused to take this medicine (covert administration), or whether it was being added to food as the person did not like the taste. We were told that when this person was admitted to the home, they were already taking this medicine in food or drink so the practice was continued. Although there was a letter from this person’s next of kin and doctor giving consent to add this medicine to food, there was no evidence of a best interests meeting, the homes medicines policy did not contain any guidance on covert administration and there was conflicting information in this persons care notes about how to give this medicine. Although this did not place the person at risk of harm, it showed a lack of understanding around consent issues and covert administration of medicines.