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Inspection report

Date of Inspection: 16 April 2013
Date of Publication: 17 May 2013
Inspection Report published 17 May 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, carried out a visit on 16 April 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and were accompanied by a pharmacist.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

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

We assessed this outcome because we had received information which raised concerns about the management of medicines at the service.

When we visited the service on 16th April 2013, we found that appropriate arrangements were in place in relation to the receipt and disposal of medicines. All prescribed medicines were available and records were kept of medicines received and disposed of. These were up to date and arrangements were in place to dispose of medicines safely. We did, however, find concerns with how the service was handling medicines.

Medicines were not kept safely. We saw that controlled drugs were not being stored in a cupboard which met legal requirements. We saw that other prescribed medicines were being stored in an unsuitable cupboard and no risk assessment had taken place to cover this. We saw that a prescribed cream was stored in a laundry area.The manager told us that a lockable medicines refrigerator, a medicines trolley and a controlled drugs cupboard had been ordered. We could not be sure that medicines were stored at the correct temperatures to ensure their quality as staff were not monitoring the temperature of medicines storage areas.

The manager told us that the doctor saw people regularly, however we did not find evidence for this on the record of healthcare professional visits for some people. We saw that some people were prescribed medicines for agitation, aggression, and mental health conditions, however there were no records of these people being seen by the community mental health team for several years.The manager told us that these people had been discharged by the community mental health team, but they still had access to them and would be able to contact them if there were any concerns in the future.

People living at the service were not able to keep and take their own medicines because of their medical conditions, therefore medicines were administered to people by staff. When we asked for evidence that staff had been trained to handle medicines safely, the manager showed us a training matrix which showed that only one member of staff had received medication training, in 2010. Inspection of training records showed that one person had not received any medication training since 2005 at a previous employer. The manager had not carried out any medicines competency assessments for staff who handled medicines and had not conducted any audits to ensure medicines were being managed safely. We saw one audit report from a local pharmacy dated May 2012.

Appropriate arrangements were not in place in relation to the recording of medicines. There were no medicines records for some medicines being stored for palliative care, including controlled drugs which were not currently in use. We looked at the records for medicines administration for people in the service. We saw that where people were given medicines in variable doses, for example "one or two tablets", the actual quantity given was not recorded. We saw that staff did not always record when prescribed creams were used. We also saw that staff were using correction fluid to make corrections to medicines records, so it was not possible to see what was originally entered. We saw that when people had allergies, this information had not been entered onto their medication charts. We saw that there was no supplementary information on medicines charts such as before food, disperse in water, to be chewed. This meant that the staff did not have appropriate information about when to give medicines and we saw that some medicines for osteoporosis were not being given at the correct times in relation to other medicines which could affect people’s treatment.