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Archived: The Yachtsman Rest Home

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Inspection report

Date of Inspection: 7 March 2011
Date of Publication: 18 May 2011
Inspection Report published 18 May 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

Poor practice when administering and recording medicines is placing the health and well being of people living in the home at unnecessary risk.

User experience

There were no specific comments made by people who use the service with regards to this outcome.

Other evidence

The manager states that no one who lives at the Yachtsman manages their own medication. There has been a recent change of medication system but staff have said that despite some advantages of the system, prescriptions have been delivered late or not at all resulting in staff having to collect them. They have therefore reverted back to the original medication system. Staff were completing refresher training on medication management on the morning of the visit.

We checked a sample of medication and medication administration records. The medication administration records sampled all showed three occasions in the last month where staff had not signed the record to say medication had been administered or refused. In most cases the medication for that date and time was no longer in the medication dosette, suggesting that it had possibly been administered but not signed for. On one occasion the medication remained in the dosette but there was no record of why it had not been administered. Medication at other times had been signed for as required. Most of these errors showed that the member of staff had not signed for the medication for any resident we checked on that date and time. These errors suggest that some staff are not administering medication as the procedure states and this practice is unsafe. Staff should be checking each resident's medication against their MAR sheet and signing when each person’s medication is checked and administered.

There have been twice daily audits of medication but these were at the same times each day and missed some times of administration and the errors had not been picked up. The audit needs amending to ensure regular checks cover a mix of or all times of day.

Staff administering medication were not familiar with the reasons medication was prescribed or the side effects of particular medications. Information must be available so that staff know about the medication people living in the home take, what effect it should have and any side effects it may cause.