You are here

Archived: Newstead House

The provider of this service changed - see new profile

All reports

Inspection report

Date of Inspection: 10 January 2012
Date of Publication: 1 March 2012
Inspection Report published 1 March 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

People were not fully protected against the risks associated with the unsafe use and management of medicines by means of making appropriate arrangements for the obtaining, recording, handling, using, safe keeping, dispensing, safe administration and disposal of medicines.

User experience

We did not speak to people about their medicines.

Other evidence

The safe handling of medicines was assessed by a pharmacist inspector. We looked at the storage of medicines and a selection of people’s medicine records and some care plans.

A Pharmacist from the supplying pharmacy had undertaken a visit and checked medicine management on 7 October 2011 and also a Pharmacist from Herefordshire PCT had undertaken a check on the safe handling of medicines on 31 October 2011. We saw copies of both reports which detailed recommendations and areas for improvement to ensure that people’s medicines were handled safely.

We found that people’s medicines were not always handled and managed safely. Procedures for the obtaining, recording, handling, using, administration and disposal of medicines were not always followed, which increases the risk of a medicine error.

There were systems in place to check that people had been given their medicines, however they did not always identify medicine errors and therefore action was not always taken to prevent them happening again. We looked at ten people’s medicine administration records and found it was not always possible to determine if they had been given their prescribed medicines. One person had been given medicines that were no longer fit for use and there was an increased risk that the medicines were no longer effective. This means that despite systems being in place they were failing to ensure that people were being given their prescribed medicines and there was an increased risk of a medicine error.

Personal care plans did not always record specific person centred information relating to people’s medicines, in particular for medicines prescribed when required (often documented as ‘PRN’). It is important that these details are available to inform staff when to recognise that medicines need to be given, especially for people who are unable to communicate verbally.

Medicines were stored securely and at the correct temperatures in order to protect people who use the service and to ensure the medicines are fit for use.

We looked at the arrangements and storage for controlled drugs. Controlled drugs are medicines that require extra checks and special storage arrangements. We found other items which were not classed as controlled drugs were stored incorrectly. This increases the risk of unnecessary access to controlled drugs and means that the service was not complying with legal requirements. We were told that this would be dealt with immediately and the items would be removed.