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Inspection report

Date of Inspection: 11 March 2013
Date of Publication: 11 April 2013
Inspection Report published 11 April 2013 PDF


Inspection carried out on 11 March 2013

During an inspection in response to concerns

We did this inspection because we received information of concern. The main concerns we were told about were the management of medicines and how people with mobility difficulties were moved. We spent the majority of our time inspecting the arrangements for medicines. This was because it was the area in which people may have been at most risk.

During our inspection we identified a number of shortcomings in the arrangements for the management of medicines. These shortcomings meant that people were not protected from the risks associated with the unsafe use and management of medicines. The most concerning of these was that some people's medicines had been out of stock for up to 11 days. This meant that they had not received the medicines prescribed for them. Other concerns related to various aspects of the recording, handling, safe keeping, safe administration and disposal of medicines. Following our inspection we made a safeguarding referral to the local authority. This was in respect of three people where we were most concerned that they had not received their prescribed medicines.

We saw two occasions when care workers moved people in a way that is viewed as poor practice. We subsequently learned that one of these people should have been moved using a hoist. They had been moved by staff manually. This meant the person had not received the correct care and was put at risk of being injured.