You are here

All reports

Inspection report

Date of Inspection: 16 May 2013
Date of Publication: 8 June 2013
Inspection Report published 08 June 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 May 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, talked with carers and / or family members and talked with staff.

Our judgement

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to safely manage them.

Reasons for our judgement

We looked at records about medication for twenty people who were living in the home on the day of our visit.

The service uses a pre dispensed system for medication. This means medication is dispensed by the pharmacist in a sealed package, which holds each days medication in a single container. The medication is delivered to the home, from the pharmacist with a printed medication administration record (MAR) which details who the medication is for, what the medication is and how often it should be given. However, some medication, although prescribed, did not have a printed MAR and staff had handwritten the instructions. This, we were told, was because the medication might have 'fallen' outside the monthly cycle and therefore had been dispensed separately or was a temporary treatment, for example a course of antibiotics and therefore was dispensed without a MAR. The homes policy for medication stated that all handwritten MAR sheets should be signed by the person completing it and countersigned. The reason for this was to make sure the information was correct and had been checked by two members of staff, therefore minimising the risk of an error being made. None of the handwritten MAR was saw had been signed or countersigned. We also found that a significant number of the handwritten MAR sheets had not been dated and the amounts of medication received had not been recorded. Therefore it was not possible to do an audit trail of the amount of medication coming into and out of the home, meaning medication could not be accounted for. We also saw that one person's MAR sheet, despite the person being in hospital at the time, had been signed by a member of staff, indicating that the person had received their medication in the home.

Some medication was prescribed “as required" or prescribed as a variable dose. However, staff did not have access to how they should determine when and how much medication should be given. This is important to ensure people were given their medicines safely and consistently. Also medication detailed as 'one or two tablets to be given' staff were not recording whether the person had received one or two tablets. Again making it difficult to account for the mediation in stock.

We noted that some medication was not being stored securely, having been left out on the medication trolley. Albeit the trolley was in a locked room, the medication should have been locked away securely.

During the visit, none of the night staff on duty were able to give out medication, despite one person having been trained. They told us that they would contact the 'on call' person to come in to give medication, including homely remedies, if medication needed to be administered. This could mean that there was a delay in people receiving medication, including medication used for pain relief.

Despite the shortfalls found, appropriate arrangements had been made in relation to the ordering, disposal of medication and the storage of controlled medication.