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Archived: Albany Park

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Inspection report

Date of Inspection: 7 December 2010
Date of Publication: 18 April 2011
Inspection Report published 18 April 2011 PDF

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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

People who use services should have their medicines at the times they need them and in a safe way.

We found that some medicines needed on a "when required" basis had not been reordered and there was no evidence that these had been stopped by the prescriber.

We found that there was not enough information for staff about some medicines being given to people.

We found discrepancies in a few cases between records and medicines used.

We found that the storage of some medicines was unsatisfactory and put people at risk of harm.

User experience

We observed lunchtime medicines being given to people and they were given correctly. We saw that the nurse took time to give people their medicines and treated people respectfully. We observed that some people had to wait for their 12pm medicines until 2pm.

Other evidence

Some people are prescribed medicines to be given” when required”. Protocols are not available for these medicines. These are needed to provide information to staff to make sure these medicines are given consistently and appropriately. This is particularly important if people have dementia or communication difficulties because they may not be able to say when they need these medicines. Some people were without these medicines, including pain relief and an angina spray, because they had not been reordered this month. There was no evidence in care records that these had been stopped by the prescriber, so these people could have been left in pain.

The eye drops being used for some people, which were labelled to be discarded 28 days after opening, were being used beyond 28 days which could increase the risk of contamination and put people at risk of getting an infection.

We checked several medicines to see if they had been given as recorded, and in two cases, doses had been recorded as given but had not been. The number of tablets given for medicines which have a variable dosage, e.g. one or two tablets, was not being recorded so it wasn’t clear how many had been given. A cream was being used for one person which had not been prescribed for them.

On one floor, 11 out of 12 people did not have their allergy status recorded on their medication records. This could put people at risk of being prescribed or given medicines that they are allergic to.

There were some issues with the storage of people’s medicines. We found a prescribed medicine in the trolley which was not on their current medication chart so had not been given this month. We found a prescribed medicine for a person living on the ground floor stored on another floor so this was not recorded on their current medicines chart. Storage of prescribed creams kept in people’s rooms was not secure, these were stored on top of bedside tables as lockable storage for medicines is not provided in peoples rooms. Some doses of medicines had been removed from blister packs and were being stored unlabelled in a plastic pot on a shelf together with another persons medicines. This increases the risk of medicines being given to the wrong person. Medicines requiring refrigeration were not stored at the correct temperatures for long periods and could have deteriorated.

We found that no audits on medicines were being done by the homes management so issues with medicines management were not being picked up. Staff had received no refresher training in medicines handling in the last two years. There were no information leaflets available for people’s medicines if they wanted to know more about their medicines.