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BMI Sarum Road Hospital Good

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Inspection report

Date of Inspection: 9 December 2013
Date of Publication: 7 January 2014
Inspection Report published 07 January 2014 PDF

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 carried out a visit on 9 December 2013, talked with people who use the service, reviewed information given to us by the provider and were accompanied by a pharmacist.

Our judgement

People were protected against the risks associated with medicines because the provider does have appropriate arrangements in place to manage medicines.

The provider was meeting this standard.

Reasons for our judgement

Following an inspection in August 2013 the service was found to be non-compliant and was asked to take actions to meet this essential standard. Therefore, a pharmacist inspector looked at the use and management of medicines within the service.

Appropriate arrangements were in place for accessing medication on discharge when the pharmacy was closed. We reviewed the batch sheet records for “over-labelling” and from the records we were assured that the labels generated for each batch were checked against a master label. Therefore we were assured that medicines were labelled for patients as intended.

We checked the records of Accountable Officers published by CQC on our website and the records for this service were accurate. Therefore we were assured that the relevant measures were currently in place for Controlled Drugs as required by The Controlled Drugs (Supervision of Management and Use) Regulations

Medicines were stored safely and securely. We checked the medicines refrigerator records within theatres. These records included minimum and maximum temperatures; therefore we were assured that the medicines were stored within the required temperature range. The provider may wish to note that infusion fluids held on the ward were accessible by the public. We were assured that medicines were stored at the correct temperatures and securely prior to administration to patients and were therefore safe to administer.

Information about medicines was managed safely. We were advised that changes to medicines were explained to people and on discharge the Pharmacist or ward nurse would discuss the person’s discharge medicines with them. The on-site Pharmacy held a number of pharmacy reference books; which were being updated as new editions were published. At ward level specific medicines information was sourced from the internet, and the nurses had access to specific guidelines on the use and administration of injectable medicines, which they found very helpful. Therefore, people would receive the most up to date information concerning their medicines.

The service had introduced a Medicines Management group. The group reviewed medication incidents; safety alerts involving medicines and changes to medicines used with representation from all departments that store medicines. The process for the receipt, logging and tracking medication alerts had been reviewed. To allow for leave and sickness, these documents were received via two different emails. On receipt they were, logged on a local database and circulated. Once circulated and actioned, the records were reviewed by the Director of Nursing and closed. We found one medicine for which the use had been restricted by the Medicines and Healthcare Regulatory Agency, when the manager of the area was made aware they removed the medicine and the shelf label immediately. Therefore, we were assured that the service had processes in place to ensure people were receiving medicines in line with current guidance.

Appropriate arrangements were in place for the monitoring of the use and administration of medicines. Regular audits of activities involving medicines were being introduced. When we inspected the service had four in-patients, we spoke to one patient who advised us that due to an allergy the medical staff had treated their pain with alternative medicines and they were pain free. Therefore we were assured that the service people received was improving though the monitoring of the service provided.