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Inspection report

Date of Inspection: 26 March 2012
Date of Publication: 24 April 2012
Inspection Report published 24 April 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

Our judgement

The home did not have fully effective systems in place to manage the risks associated with the management of medication.

User experience

We did not speak with people using the service about how the home manages medication. Everyone who lived at the home when we visited was not able to manage their own medication, and therefore relied on the staff to do this for them.

Other evidence

We had not planned to review the management of medication at this visit, but we became aware that the rooms in which medication was being stored were very hot and that this was potentially unsafe. This is because most medications should be stored below 25 degrees Centigrade. The temperature in one of the storage rooms had been recorded as 29 degrees Centigrade. The registered manager told us that she was aware of this issue and had made the company which owns the home aware of it. She said that they were hoping to get an air-conditioning unit installed so that medication could be kept at the correct temperatures.

We saw that each person had a risk assessment to show if they were able to manage their medications themselves. Care plans included a list of each person’s medication. We checked three care plans, and found that the lists were up to date and included all current medication.

Some people had been prescribed medications, such as painkillers, to be taken on an “as required” basis. There were clear records to show when these medications should be given. The Medication Administration Record (MAR) charts for three people taking “as required” medication were fully completed with no gaps.

One person was being given their medication covertly. This means that the medication was being hidden in food or drink. There was a clear record of how the decision to do this had been made, and the record included evidence that it was in the person’s best interests to be given their medication even when they did not wish to take it.

Some people had been prescribed creams or ointments. We saw that the records to show that these had been applied were complete, and provided a full record of when staff had used the creams and ointments.

One person had been prescribed a thickener for their drinks but staff were not able to find the thickener and there was some confusion about its usage. The registered manager assured us that she would check with the doctor and would ensure that there was clear information for staff about this thickener.