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Inspection report

Date of Inspection: 30 December 2010
Date of Publication: 9 February 2011
Inspection Report published 9 February 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

Not everyone using the service received their medicines as they were prescribed. Recording and auditing systems did not ensure that people's medication was managed effectively.

User experience

We did not gather any information from people who use the service in relation to this outcome.

Other evidence

All medicines were stored in an appropriate metal lockable cabinet in the office. Medication administration records (MAR) were held in a folder. At the front of this file there was information about the medication people were prescribed and additional information about side effects. The service has a medication policy in place, which is reviewed. The service uses a monitored dosage system (MDS) for the administration of medicines. This process means that the service has a contract with a local high street pharmacy that provides the medication on a 28-day cycle, with prescriptions supplied by the person’s GP. We saw that medication cabinet temperatures were being recorded to ensure that medication was being stored in the correct environmental conditions. We saw that they were being stored correctly. There were no controlled drugs.

We found that, where medication was stored in bottles or boxes, these had not been dated once opened. This would not ensure that the medication was within its shelf life if not taken on a regular basis. On several occasions, medication instructions had been written on to the MAR. These instructions had not been signed or stock checked in by two people. On one occasion, one person was prescribed olive oil for their ears. This was not booked in, did not have a signature or date and did not detail the instructions for administration. We also found that one person was prescribed medication that was initially dispensed on 28 October 2009. The medication was due to expire at midnight of the day of the site visit. There were no medication audits due to take place later that day. This was brought to the attention of the manager and the medication removed for return to the local pharmacist.

In a separate instance, one other person's medication was seen in a small pot in the medication cupboard, with a label stating the initials of the person. The medication was not easily identifiable. The medication had already been signed by staff to state that it had been taken. There were no additional records of notes made about this medication, of errors in administration or refusal to take the medication by the person.

There is a system at the service where daily checks occur to ensure that all medication had been signed for. Medication audits also occurred. However, none of the audits identified the issues we had identified, which raises concerns about the quality of these audits. Training records showed that six people are due their medication refresher training in 2011, an additional two people were highlighted as being outside the provider refresher time scales and therefore needed the training. A further two people were not recorded as completing any medication training. Records showed that 15 people had received training and were still within the refresher time scales by more that six months.