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Inspection report

Date of Inspection: 6 July 2011
Date of Publication: 26 September 2011
Inspection Report published 26 September 2011 PDF | 68.87 KB

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 reviewed all the information we hold about this provider, carried out a visit on 06/07/2011, checked the provider's records and talked to people who use services.

Our judgement

The service did not fully protect people against the risks associated with the unsafe use and management of medication by means of the making of the appropriate arrangements for the recording, handling, using, safe keeping, safe administration and disposal of medicines.

User experience

People who we spoke with said that the nurses and care staff were very good at calling out the GP if they felt unwell. People said they got their medication on time and how they wanted it to be given, such as with orange juice or water or after their meals.

Other evidence

The service was using a local pharmacy for the supply of their medications and had a monitored dosage system where tablets were supplied in a "pop out" blister pack.

Checks of the staff training plan showed that 90% of staff had done medication update training in the last 12 months.

Each person using the service had a medication front sheet detailing any allergy information and how the person liked to take their medication. It also informed staff about where to apply any lotions or creams and when/how to administer "as directed" medication.

We looked at the medication system and records on the nursing unit and we found that the working practices of the staff were unsatisfactory and could put people using the service at risk. For example at 14:45 when we first looked at the records we found that the mid day medications had not been given out. We alerted the manager who informed the nurse on duty, who then started the medication round. The manager informed us that the reason for the delay may have been that staff had been in a meeting.

We found evidence of missing signatures on a number of medication sheets where staff had not signed to say that they had given out medication. We checked the stock levels which showed the medication had been administered.

Staff were performing tasks by "rote" without considering if the task was necessary. For example a number of people had their blood sugars taken by the staff, but there was no consistency to the time that this was done and no information on the medication sheet to tell staff how often it was to be carried out.

We looked at the controlled drugs kept in the service and their controlled drug register. The medication was stored correctly and accurately accounted for in the register.