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Inspection report

Date of Inspection: 9 December 2013
Date of Publication: 16 January 2014
Inspection Report published 16 January 2014 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 9 December 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 and talked with staff.

Our judgement

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

Reasons for our judgement

We spoke with three people who lived in the service. One person said, “I get my tablets, they’re locked in the shower room.” Another person said, “I get my tablets and the staff put my cream on.” The third person told us that they administered their medication independently which included ordering and collecting their tablets.

We spoke with a staff member who said, "The medication procedure is alright, we know what we are doing. Some staff don't pick up on medication issues and leave it to the person who orders them [the medication]."

We spoke with three staff who told us that they had received medication training recently. We saw from training certificates and the training matrix that this was the case. An annual competency assessment formed part of the medication policy. During our inspection, we looked at three staff files and found two staff were still undergoing medication training and had not been signed off on their medication competency assessments. The provider forwarded a completed copy of one these forms for one staff member the day after our inspection.

We looked at the medicine stored in the flats of two people living in the service. We found that these were stored securely in a locked cupboard for both people. In one person’s flat we found that the cupboard and fridge temperature were being monitored on a daily basis and that these were always within acceptable limits. We also found that the fridge in one person’s flat was lockable.

In the other person’s flat, we found that the temperature recorded for the cupboard where medication was stored was above the acceptable limit of 25°C on four occasions during November and December 2013. A member of staff told us that if the temperature in the cupboard becomes too high, the medicine should be taken to the main medication cupboard. However they had found that the temperature had been recorded as above 25°C on the previous day and the medication was still there in the morning. Most drugs are licensed for storage at a temperature up to 25°C because, at higher temperatures, there is a risk that their efficacy will be adversely affected (Royal Society of Medicines).

We saw that there were no recordings of when medication had been removed from a position where the temperature was too high. This meant that the provider could not always be reassured that medicine was being stored safely.

The member of staff took the medicines to the main medicine cupboard to be stored. The cupboard contained a medication trolley where the medicine removed from the person’s room were to be stored. The temperature of the cupboard was monitored on a daily basis and was within acceptable limits. However we found that there was a thermometer available in the trolley, but these temperatures were not monitored. On the day of inspection the temperature of the trolley and the cupboard was different. This meant that the provider could not always be reassured that medicine was being stored safely. At the time of the inspection, the temperature of the trolley was within acceptable limits.

We looked at the Medicines Administration Records (MAR) for four people who lived in the service and saw that they included a photograph of each person. The MAR charts provide a record of the medication taken or not taken by a person. We found that for the tablets which were being given on a regular basis, for example every morning, there were no discrepancies with the recordings made by staff. This meant that people were receiving their medication in line with the prescription from their doctor.

We found that some of the instruction on the MAR charts could be confusing to staff. For example it stated to administer the medication ‘when required’ and/or ‘as directed’ with no supporting information to staff. We saw that this was not in line with the provider’s medication policy and procedure. The manager said that they had recently changed the pharmacist the service was using and that this was one of the