You are here

Archived: Andrew Cohen House Good

The provider of this service changed - see new profile

All reports

Inspection report

Date of Inspection: 22 January 2014
Date of Publication: 22 February 2014
Inspection Report published 22 February 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 22 January 2014, 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 reviewed information given to us by the provider. We talked with commissioners of services.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

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 the manager about medication training. They confirmed that qualified nurses administered people’s medication and they had recently completed refresher training. This was confirmed by the two nurses spoken with during our visit.

Medicines were kept safely. All medicines were stored in locked trolleys and the trolley was stored in a clinical room when not in use. This ensured that unauthorised people could not access or take medicine that was not prescribed and which might harm them or others.

We found that some people were prescribed controlled medication. This was stored separately and stock held was logged in a register. Medication held was checked daily by nursing staff. We counted the controlled medication held for one person and found the stock matched their medication records. This indicated the controlled medication had been administered as prescribed.

Medicines requiring cold storage conditions were being kept in secure fridges. We found that the fridge temperature was not being monitored properly. The service was not able to show that the medicines being stored in these fridges were being stored within the correct temperature range. A failure to store medicines at the correct temperature could mean that they would not be effective to treat the conditions they were prescribed for.

We observed one nurse asking people if they were ready to take their medication and that time was spent talking with people while they took their medicines. We saw that drinks were offered to people when needed. This meant that the person was valued as an individual and that staff understood the importance of supporting people to take their medication. We saw that people’s medication record contained a photograph of the person and any known allergies. This would help to ensure that the medication is given to the right person.

One person was given some pain relieving medication, however the nurse who administered this did not immediately sign the medication record. We found that this was still the case more than an hour later. We spoke with another nurse who was on duty and they confirmed they had not been made aware this medication had been given. This put the person at risk of being further pain reliving medication and exceeding the safe dose.

We looked at the medication records for one person who needed staff to check their pulse before their medication was administered. Records showed this had usually been done but there had been some recent gaps in the records. We looked at the records for a second person who also needed their pulse to be checked and found that records showed staff were doing this.

We looked at the medication administration records for four people over a one week period. We saw that for one person their record had not been signed for one of their medications on one occasion. A count of the number of tablets in stock indicated this had not been given. We looked at the system in place for checking people were being given their medication as prescribed. We found that a recent audit of medication had been undertaken and this showed that for a number of people the medication held in stock for them did not correspond with the medication that had been recorded as administered. This showed that people had not been supported to take their medicines as prescribed. There was no evidence to show that any action had been taken in response to the audit to prevent further reoccurrences of people missing their medication..