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Inspection report

Date of Inspection: 11 February 2011
Date of Publication: 7 April 2011
Inspection Report published 7 April 2011 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

Our judgement

We found cases where people who use services have been asleep, meaning they have missed their prescribed dose of medications on those occasions. We also found cases where the time of medications of some people who use services had been changed from a prescribed time of 'at night' to 1800 hours on the MAR, meaning they have had prescribed medications earlier than advised in writing by the prescribing doctor. Both of these matters may have adverse effects on the health of the involved people who use services. The registered people have failed to ensure that people who use services are protected against the risks associated with the unsafe use, administration and management of medicines by means of the making of appropriate arrangements for the recording, using, and safe administration of prescribed medicines. We are taking enforcement action against the provider for this essential standard.

User experience

One person was asked about medication. They said, “You get tablets to wake you up''. They confirmed that having medication was fine and that it could be refused.

We observed people being asked if they wanted their medication. Staff dispensed the medication in a hygienic manner, and encouraged people to take their medications in a respectful and involving manner.

Other evidence

When we arrived at the service the medication trolley was unattended in the hallway and not secured to the wall. This failed to keep medication appropriately secure.

We looked at the current Medication Administration Records (MAR) of people who use services, and compared some of these entries with the relevant medication containers in the medication trolley. We also asked to look at the most recent copied prescriptions for everybody, and were supplied with copies for ten out of the fourteen people who were receiving medication according to the MAR.

Administrations on the MAR were up-to-date, and there were no gaps in administration recordings. There was also the good practice of the service listing what each medication was for, in front of each person’s MAR.

We found four cases where the current MAR of the person using services had a number of administrations marked to indicate that the person was asleep. The registered manager confirmed that these people were asleep, and clarified that the person did not therefore receive that prescribed dose of medication.

This means that there were seven occasions within the 19-day period up to our visit when one person who uses the service did not receive their prescribed dose of five medications. There were nine occasions within the same period when another person did not receive their prescribed dose of four medications. There were four occasions within a six-day period up to our visit when a third person did not receive their prescribed dose of one medication. There were two occasions within an eight-day period of the current MAR when a fourth person did not receive their prescribed dose of one medication. Failure to receive these prescribed medications put these four people at risk of their health conditions not being treated properly.

There were also four out of twelve administrations within a four-day period on the current MAR of one of these people when they did not receive their prescribed dose of two short-term antibiotic medications through being recorded as asleep. This person was not appropriately supported to overcome the infection that these antibiotics were prescribed for through regular administration, which put them at risk of their health conditions not being treated properly.

We also looked at the previous MAR for one person, to confirm that documented GP input had resulted in timely acquisition of short-term medications. The MAR showed that the course took six days to complete instead of the five prescribed for, because the person was marked as asleep for two consecutive doses of the twice-daily medication. This person was not appropriately supported to overcome the infection that this antibiotic was prescribed for through regular administration, which put them at risk of their health conditions not being treated properly.

We found three cases where the current MAR of the person using services had a number of administrations being given at 1800 hours, contrary to the prescribed instructions on the medication containers and their copied prescriptions stating ‘at night’.

In one case, the person had had three medications earlier than the prescriber intended for the previous 18 days. The other two people had each had one medication earlier than the prescriber intended across the previous 18 days. This may have had an adverse effect on the three people’s health.