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Inspection report

Date of Inspection: 7 May 2013
Date of Publication: 1 June 2013
Inspection Report published 01 June 2013 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 7 May 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

Our judgement

Systems were in place for storing, recording and handling medicines.

Reasons for our judgement

During the inspection we look at the way medicines were stored and managed in order to check that people received their medicines safely and as prescribed. On 7 May 2013 we identified some errors and gaps in recording. This meant the manager could not be confident that people had received their medication appropriately. We visited the home again on 10 May 2013 and found no errors or gaps in the recoding or documentation of medicines.

During the inspection we looked at the Medication Administration Records (MAR). We saw documentation, for the day of the inspection, which had not been appropriately completed. When we visited the home again on 10 May 2013 and found all documentation appropriately completed and signed by staff.

We checked the quantity of medication for four people to ensure the correct amount were in stock. We noted two errors in stock levels, which identified different stock holdings to that recorded. On 10 May 2013 we checked medication for a further four people, we found the quantity of tablets in stock was accurate. The staff conducted a weekly audit for medicine management. However the recording process in place made it difficult to establish the expected stock levels. We discussed this with the manager, who recognised the benefit to having a recording and auditing process where stock holdings were easily identified.

We observed a senior carer dispensing medication to people in an encouraging manner, taking time to inform people what they were taking. During this time they were the only member of care staff in the area. We saw they were distracted from giving medication on a number of occasions. Being disturbed whilst dispensing medication increased the risk of an error being made. The provider may wish to review the process for dispensing medication to ensure staff are not disturbed and the risk of errors is reduced.

The service had secure storage for medication and the Monitored Dosage System (MDS) was used for most medicines. This meant medicine’s were dispensed into monthly blister packs by a pharmacist. We saw medication had been appropriately dispensed from the MDS.

We saw that separate secure storage and signed records were available for controlled drugs. We checked the documentation and quantity for one controlled drug and found this to be accurate.

We saw from training records that senior staff, who had responsibility for dispensing medicines, had received training. Senior care staff were assessed once a year to ensure they were competent in managing medication.