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Archived: Partridge Care Centre Requires improvement

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Inspection report

Date of Inspection: 8 August 2012
Date of Publication: 21 September 2012
Inspection Report published 21 September 2012 PDF | 76.02 KB

People should be given the medicines they need when they need them, and in a safe way (outcome 9)

Meeting 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 reviewed all the information we hold about this provider, carried out a visit on 08/08/2012, observed how people were being cared for, talked to staff and talked to people who use services.

Our judgement

The provider was meeting this standard. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

User experience

We asked a person who used the service if they get their medication on time. They said, "I get it every day. They say, 'Don't forget you haven't had your tablets.'"

Another person confirmed they received their medication on time and told us this was done in the way they preferred. They said, “Yes, they are very good. They bring it to me every morning, they give me all the tablets in one pot as that’s how I like to do it, not all this one at a time business, and that’s it.”

Everybody that we spoke with confirmed that they had not had any problems in receiving their medication.

Other evidence

Prior to our inspection of the 7 and 8 August 2012, we had received information from the adult safeguarding authorities informing us that there had been an increased number of safeguarding incidents raised relating to medication errors at the service. We were informed by the Registered Manager that these concerns were due to the errors of a particular member of staff, who had since left the service. This account corroborated with the dates of the information that we had received.

There were suitable arrangements in place at the service to obtain medication. We were informed that medication was ordered by a senior carer or nurse at the service and that prescriptions were checked. We saw documents which demonstrated that advice was sought from a person’s GP when medication was discontinued or when a person persistently refused their medication.

We checked that the medications in the blister packs correlated with the Medication Administration Records (MAR sheets). The MAR sheets were updated when medication was not administered or lost and the reasons for this. When people were prescribed medication on an ‘as required’ basis, we saw that there was information detailing when this had been administered. This confirmed that there were appropriate arrangements in place for the recording and safely administering medications.

In our report of April 2012, we noted that when people received medicated patches, that the positioning of these had not been recorded. This was advised by our pharmacist inspector as it can cause the person discomfort if the location of the patch is not changed. During our inspection we noted that the situation of the patch was documented. This enabled the site of the patch to be alternated and therefore, the discomfort to the person to be minimised.

We saw people received their medication in a safe way and that this was completed with regard to people’s dignity and personal choice. We saw that staff informed people individually that it was time for their medication and asked them if they were ready to take it. Staff stayed with the person whilst they took their medication to ensure that this had been taken. Staff also quietly explained to one person that, as they were taking a big tablet, they would need to chew. They told another person that the particular tablet was for their Parkinson’s disease.

In our report of April 2012, we noted that people may have received their medications too close together as the time the medication was administered was not recorded. We saw that this was still the case. During our inspection, we observed a person receiving their morning medication at 10:52am. We spoke with the member of staff who had administered the medication. They confirmed that they did not write down the time the medication had been administered, but said that they were working all day so would ensure that the lunchtime medication would not be given too early. However, we pointed out to them that this would be an issue of they were taken unexpectedly ill, for example and the covering member of staff would not be aware of the timings.

The Registered Manager advised us that they had trialed a system of recording the medications, but this had proved difficult. They agreed with the concerns that had been raised and said that they would be looking into this issue further.

Medications were stored in locked trolleys in a locked clinical room. Controlled drugs were kept in a cupboard within the clinical room. Temperatures were taken of the clinical room twice a day to ensure that medications were not spoilt. There were appropriate systems in place for the safekeeping of medications.

With regard to disposing of medications, we saw that these were appropriately recorded in a returns box, safely stored awaiting collection and then signed out when collected. This ensured that there were systems in place to ensure the safe destruction of medications.