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Inspection report

Date of Inspection: 2 July 2013
Date of Publication: 30 July 2013
Inspection Report published 30 July 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 2 July 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service.

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 saw medicines were kept in a locked portable box next to a table in the downstairs office, this office was left unlocked. However access to this office was by another door at the top of the steps which was locked by a key code which only staff had access to. The provider told us the home did not have any controlled drugs on the premises and did not have the appropriate cabinet to store them.

We looked at nine medicine administration records (MAR). We saw the front sheet had a list of medication which was administered from a dosette box. The dosette box was filled by the pharmacist and had a list of the medicines on the back of the dosette box. We found this did not correspond with the tablets in the dosette box; there were more tablets in the dosette box. We talked to the manager/senior carer staff about this, who explained if any tablets were dispensed in its original packaging they would add them to the dosette box at the beginning of each week. This meant the staff were secondary dispensing the medication. This was unsafe practice because the staff who had administered the medication did not check the original packaging to make sure the dose was correct and so there were no specific directions they needed to follow.

We also saw one person had been given a tablet but the MAR had not been endorsed with who had administered the tablet. While on another occasion we saw the MAR sheet had been endorsed with a staff signature as a tablet being administered when in fact the tablet was still in the dosette box and had not been administered. This showed to us people who used the service were not protected against the risks associated with unsafe uses of medicines as information was not properly recorded.

The manager/senior carer told us they had received the appropriate training. The manager/senior carer staff told us that the medication was disposed of by the pharmacist and the provider dealt with this. We saw evidence of medication that had been returned to the pharmacist.