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Archived: Lammas Lodge

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All reports

Inspection report

Date of Inspection: 21 June 2011
Date of Publication: 8 August 2011
Inspection Report published 8 August 2011 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

People had been put at risk of poor health outcomes because their medicines had not always been safely managed.

User experience

One person had been prescribed medicines that were to only be given when they displayed certain behaviours. There was no guidance for staff about the doctor’s instructions with the medicines records. The team leader said guidance had been written but it was not yet in the medicines folder. The team leader did not think the guidance included all the information we would expect, such as the minimum time frames between doses.

A nurse from one person’s funding authority told us that they had found that not all the staff team were suitably trained to administer the medication this person may need if they had an epileptic seizure. With the involvement of this person’s family other arrangements were put in place while training was arranged. It was later established that nine staff had been trained but the information about this had not been easy to find.

Other evidence

Training records showed that staff had been provided with the appropriate level of training on how to administer medicines. The support staff had attended a foundation course and the team leaders, who administer the majority of medication and hold overall responsibility on each shift, had attended advanced training.

During our visit we checked on how well the medicines of the people who live in the main house were being managed. No one was looking after their own medicines due to the level of their support needs. There was a medicines room and the door was fitted with a domestic lock. The team leader on each shift holds the key.

The main medicine cabinet and the control drugs cabinet were in this room. We found that the keys to both cabinets had been left in the doors. The team leader said the keys were meant to be stored in a locked key safe but this was not always done. When we had finished looking at the medicines she left the keys in the cabinet doors again. This indicated to us that this was common practice. because the door to the room was locked people in the home could not access the medicines, but the security arrangements were poor and not in line with the home’s procedure. We checked the controlled drugs during our visit and all were accounted for. Appropriate records were being kept for these.

The medicine administration records we saw in the main house were clear and showed all doses had been given and signed for that day and over the past week.

One person who lived in a flat had not had their medicines included on the record of medication received into the home or in the stock checking system. This meant we were not able to check if the correct number of tablets were in the home. When social care staff visited shortly after us they found that the records for this person were not completed properly and contained gaps. This could mean that some doses had not been given to the person in line with their doctor’s instructions.