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Inspection report

Date of Inspection: 1 April 2011
Date of Publication: 4 May 2011
Inspection Report published 4 May 2011 PDF

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

Our judgement

The audit of medication and inspection of records of receipts, administration and disposal of medication suggested that the home had complied with the warning notice issued on 28 February 2011.

The home now has procedures in place to protect service users against the risks associated with the unsafe management of medication.

User experience

We observed that six people were still asleep when we started this inspection and the care workers checked on them regularly and offered them their medication when they were ready. We saw one lady given a late breakfast followed by her medication. No people were able to self medicate. We saw that several people had difficulties with speech and swallowing and there was evidence of referral to dieticians, speech and language therapists and specialist consultants. Records showed that this was also to ensure that the appropriate form of medication could be administered in an appropriate way.

Other evidence

This inspection was carried out to check compliance with a warning notice issued to the home on the 28th of February 2011 because of a failure to protect service users against the risks associated with the unsafe use and management of medicines.

We saw that all but six people had received all their medication over the last 6 weeks and that the records were signed appropriately. There was just one omission in records of administration and the counts of tablets suggested that all people were receiving their medicines as prescribed. The GP had reviewed the timing of some night time medications and had written individual letters confirming the changes.

We saw that medication was well organised and stored securely. Medication was supplied in original patient packs and the Mediform Medication Administration Records were handwritten. All records for receipt, administration and disposal were complete. There was one exception with a liquid anticonvulsant where there was a gap in administration. The manager knew about this and the daily care record showed no adverse outcome.

We saw no records of medicines not being given because people were asleep. When we counted tablets all could be reconciled with the records.

We saw evidence of review of medication by the GP and when medicines were discontinued this was recorded in the healthcare section of the care plan. The GP had reviewed the timing of night medications and instructions on the prescriptions correlated with what was being given on the Medication Administration Record. We were told that the pharmacist labels would also correlate when they were printed for the next medication cycle.

The home had updated its medication policy and had included a procedure for referral to the GP if a dose of medicine was refused or missed for more than 2 days.