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Archived: Ryecroft Private Residential Care Home Inadequate

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Inspection report

Date of Inspection: 11 December 2014
Date of Publication: 20 February 2015
Inspection Report published 20 February 2015 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 11 December 2014, observed how people were being cared for and talked with people who use the service. We talked with staff and talked with commissioners of services.

Our judgement

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Reasons for our judgement

Prior to our visit, the Local Authority had raised concerns with us about the way in which medicines were managed and administered at the home. We used this information to plan our visit. On the day of the inspection, we found that medication was not stored, administered or managed in a safe way.

Most medicines in current use were kept in a locked trolley however the trolley was not secured to the wall. During the morning medication round, we observed that medication was left unattended on the dining room table and we also found a variety of prescribed creams and inhaler medication stored in people’s bedrooms. This meant medication was not always stored securely, leaving the medicines accessible to unauthorised staff, visitors and people living in the home.

We saw that one person’s prescribed creams and medications were stored in a box on top of a radiator shelf. A thermometer in the box indicated the medicines were stored at 30 centigrade. The majority of medicines should be stored at temperatures no greater than 25 centigrade. This meant there was a risk that the medication may not have been safe to use or may have lost its effectiveness.

In one person’s bedroom we found four dispensers of prescribed creams and two different types of prescribed inhaler medication. We looked at this person’s care file and saw that they were identified as having dementia. The Mental Capacity Act 2005 requires all those working with people who potentially lack capacity to continually assess the person’s capacity to make a particular decision or judgement at any given time. We saw that no assessment of the person’s understanding of and capacity to self administer their medication safely had been assessed. There had also been no assessment of the risks. This placed the person’s health, welfare and safety at considerable risk.

We observed a medication round being undertaken by the manager and the team leader. We saw that they were both constantly interrupted. For example, we saw that the administration of medication to one person in their bedroom was undertaken by the manager shortly after 10 am. The manager was interrupted by the team leader who then took over the administration of the medication and the manager left the person’s bedroom. The team leader was then interrupted by the provider and two care staff who wanted to support the person to get dressed. Constant interruptions and distractions increase the risk of medication mistakes being made that may cause unnecessary harm to people.

Interruptions during the medication round also meant the majority of people experienced substantial delays in receiving their medication at the right time. For example, some people whose medication was due to be administered at 9am did not receive their medication till after midday. This meant people were not given the medicines that were important to their health and wellbeing when they needed them and in a safe way.

We checked a sample of people’s medication administration charts (MARs) and found discrepancies in all four charts. For example, some medication was signed for as administered but the medication was still in the person’s blister pack and some medication had not been signed for, but was missing. This meant that medication records relating to the safe administration of medication had not been correctly completed and some medications were unaccounted for.

On checking people’s MAR charts we also saw that two other people in December 2014 had not received some of their prescribed medication for over seven days due to insufficient stock at the home. We raised this with the provider but were given no satisfactory explanation as to why this medication was not sourced appropriately. People are at serious risk of harm when they do not receive their medication as prescribed.

We reviewed records relating to staff medication training. We saw that staff training was out of date. This meant that staff who were administering medic