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Thomas House (St Helens) Limited Good

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Inspection report

Date of Inspection: 23, 28 January 2013
Date of Publication: 27 February 2013
Inspection Report published 27 February 2013 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

We looked at the personal care or treatment records of people who use the service, reviewed information sent to us by other organisations, carried out a visit on 23 January 2013 and 28 January 2013 and observed how people were being cared for. We checked how people were cared for at each stage of their treatment and care, talked with people who use the service, talked with carers and / or family members and talked with staff.

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

During our inspection of Thomas House, we checked the administration recording and storage of medication. We found some discrepancies. We saw errors on the medication administration records (MAR) for eight people living in the home. For example, one person’s recorded number of tablets did not correspond with the actual amount of tablets.

Seven people had documentation in their files to indicate that they were receiving various external creams. In each case the creams were no longer being administered. We saw five MAR sheets with no recorded dates for when the medication had commenced. This means people's health and welfare was being placed at unnecessary risk because of poor recording.

We asked the registered manager to show us the most recent medication audit. We were shown the audit for December 2012. We found the audit was incorrect when it was compared with the medication records for the same period.

We (CQC) received information, identifying some medication concerns. St Helens contracts monitoring unit had recently carried out an inspection as part of their investigation. It had been alleged that medication was being left with people, without the staff member waiting to observe if the medication was actually taken. The investigation carried out by the monitoring unit found this allegation to be substantiated. We discussed this with the manager and we were informed that staff medication competency assessments had been carried out and staff administering medicines were aware of the correct procedures to follow.

During our inspection (23/01/2013) we observed a member of staff give a person a tablet at the dinner table and then left the person, without waiting to check if the tablet was taken. We observed the person to have the tablet in their hand for five minutes before taking it. In discussion with the provider and the manager it was acknowledged that medication administration was not in accordance with the home’s policy.

We have been informed by the Local Authority contracts department that one further medication issue had been referred to them from the PCT medication management nurse. Also the monitoring officer from the contracts unit had discovered another medication error, in between our first visit and our second visit. In each case the GP for each person was informed, which prompted visits from their GP’s to ensure that people were not at risk.

On our second visit (28/01/2013) we were informed by the manager that the errors regarding the administration and recording of medication had been appropriately dealt with.

The issue regarding external creams, we were informed that the incorrect information had been removed from people’s medication files. We were also informed that daily, weekly and monthly checks would be carried out. This was to ensure that medication procedures would be more robustly managed and to help ensure that people using the service were safe and protected from potential medication errors. The manager informed us that they were in the process of carrying out a medication audit. We did not see this audit.