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Archived: Parklands Good

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Inspection report

Date of Inspection: 21, 25 May 2012
Date of Publication: 21 June 2012
Inspection Report published 21 June 2012 PDF

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

Not met 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 provider was not meeting this standard. People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines. We judged that this had a moderate impact on people using the service and action was needed for this essential standard.

User experience

People who lived at the home were spoken with, they said,

“Here she comes! (staff) It’s time for everyone’s tablets.”

“Yes, they do the tablets every day, without fail.”

Other evidence

Prescribed medicines were not given to people appropriately.

When we visited the home, we looked at the medication records held on behalf of people who lived there.

We checked to see if good medication practices had been carried out and found, for example that each person’s medication record had their photograph to help staff make sure that they administered medication to the right person. Detailed notes were kept on the back of the medication administration sheets which were written when any unusual events had taken place which had affected the way that medication had been administered.

Some people at the home needed to take drugs which required arrangements where they were ‘controlled’. All of the controlled drugs held were stored correctly. We checked a sample of records for three medicines and found that these had been properly administered with the correct amounts held in stock.

We checked the stock of other medicines at the home to see if records were accurate and if the number of tablets held matched with what should have been there. We found that records that had been completed by the senior in charge when they had administered medication from the homes ‘monitored dosage system’ (this is when the pharmacist makes up the daily amounts of medication each person needs), were accurate. This meant that the people who had their medication in this way had received the treatment they had been prescribed.

However, when we looked at records for three people who had medicines which were not in the monitored dosage system, we found that there were

more in stock than there should have been.

For one person the senior in charge could not tell if they had been given one or two tablets, as they had been prescribed, because this had not been recorded so could not tell if the remaining stock was correct or if medication had been given.

We found that a further two peoples medication records for the treatment of serious illnesses did not match the numbers of medicines that should have been left in stock. The senior told us that she could not tell if they had been given the correct levels of medication or not.

We also found that for one person, the home had not made sure that their prescribed treatment was in stock and they had missed five dosages over two days. The senior in charge of medication told us that this medication would be in stock at the home later on the same day.

The manager agreed that she could not tell from the records kept if these people at the home had received the medication and treatment that they had been prescribed or not.

The manager told us that she would carry out an investigation into the administration of medicines at the home and make improvements.