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Archived: Branston Court Care Home Good

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Inspection report

Date of Inspection: 13 November 2012
Date of Publication: 8 December 2012
Inspection Report published 8 December 2012 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 13 November 2012, 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, talked with staff and talked with stakeholders.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

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

Reasons for our judgement

We looked at the way medicines were managed to check that people were receiving their medicines safely and as prescribed. The service had secure storage for medication and the monitored dosage system (MDS) was used for most medicines . This meant medicines were dispensed into monthly blister packs. Medication was stored in a locked cupboard and the medication administration records (MAR) were inspected along with the medication systems. We were informed the qualified nursing staff administered medication.

We looked at three people’s medication records to ensure people were receiving their medicines as prescribed. We found that each person had received additional medicines following an admission to hospital. People had been discharged with new medicines.

We tried to carry out an audit of the tablets to determine whether people had received their medicines as required. We could not carry out a suitable audit as the amount of medicines recorded did not match the number of medicines that should have been kept in the service. The quantity of medicines received into the home were not always recorded correctly. The staff had been dispensing tablets from the blister packs dispensed from the local pharmacy and tablets dispensed from the hospital.

The MAR sheets had gaps which did not record why medicines had not been administered. The registered nurse agreed that the current system did not enable us to audit the tablets.

We saw a quality audit had been completed for medicines the week prior to our inspection and had identified concerns in recording medicines. The registered manager agreed an action plan would be developed and the medication system reviewed, to ensure the system was safe and people were receiving medication as prescribed.

We found that the medication fridge temperatures were monitored daily and records were kept to confirm that medication was stored appropriately. This meant that staff had taken action to ensure that medication was stored at the correct temperature.

During our SOFI observation we observed medication being given to people by a staff member. The staff sat next to the person and explained to each person that they were giving them their medication. We saw that people willingly took their tablets and were offered a drink. This meant the medication was offered in a relaxed and sensitive manner.