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Inspection report

Date of Inspection: 14 January and 14 June 2011
Date of Publication: 23 August 2011
Inspection Report published 23 August 2011 PDF

People should be given the medicines they need when they need them, and in a safe way (outcome 9)

Enforcement action taken

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

People did not have their medicines administered to them safely, because staff did not have the competency, training and skills needed.

Published guidance about how to use medicines safely were not being followed.

User experience

We did not talk to people about this outcome.

Other evidence

We looked at the MARs for 9 service users dated week beginning 18 June 2011 to 05 July 2011, with the exception of service user, dated 21 May 2011 to 05 July 2011. From these records we saw that there were unexplained gaps on the MARs where the administration of medicines had not been recorded. This meant that it was not possible to determine if the service users had received these medicines, as prescribed, on these dates.

There was inconsistent practice among staff for the recording of ‘as and when required’ PRN medication. The majority of staff had left the administration record blank, whilst a few staff had on only four occasions used the appropriate non-administration code for one service user. This meant that it was not possible to determine if the service users had been offered, refused or received these medicines, as prescribed, on the dates when no entry had been made.

There was a record of the quantity of controlled drug medicine administered, to service users for variable dose medicines; however, we found that the records for the amount held in storage were not clear. This meant that stock control systems were not robust.

There was no clear system used to record the stock of medicines held in the home for medicines not supplied as part of the Boot’s monitored dosage system. This meant that stock control systems were not robust.

External medication applied by care staff was not always documented as administered, for example gels, and creams, emollient. This meant it was not possible to determine if service users had received their medication as prescribed.

There were gaps on one hand written entry on the MAR sheets, including a second staff signature to verify the medicine details and instructions were correct. This meant that systems to help prevent recording errors were not consistently applied.

We looked at the MARs chart for week beginning 21 May 2011 we were able to ascertain that support staff, from shortly after one service user’s admission 16 months ago, and up until 25 June 2011 had been administering Novax 30 penfill injection twice daily. On 5 June 2011, a senior support staff told us that only 1 support worker had been trained by a District Nurse to administer this injection. When we checked the training records for this particular member of staff, we found that there was no record of this training having taken place. We were told that 3 other staff had been shown how to administer the injection by the previous registered manager (who was not qualified to provide such training). This meant that service user was placed at risk by receiving medicine administered to him by staff that were not qualified or trained to do so. Following a safeguarding meeting held on 25 June 2011, from 26 June 2011 the District Nursing Team were administering this medication.

We looked at each support workers individual training records. These records showed that only 2 members of the support staff had been appropriately trained to administer Midazalam. This meant that 2 service users were placed at risk by receiving medicines administered to them by other support staff that were not qualified or trained to do so. They also showed that accredited medication training had lapsed for the majority of staff. There was evidence of some in house training provided by the previous registered manager.

This meant that the medicines in the custody of the home were not handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society and the requirements of the Misuse of Drugs Act 1971.

We looked at the organisations standard staff induction training record. The medication record stated: All medication procedures should be shown and described to the new staff member. This should include how medication is stored, administered, ordered, recorded returned and reporting of wrongful drug administration. Information of how the service tracks ordering of medication from Do