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Oakwood Residential Home Good

All reports

Inspection report

Date of Inspection: 23, 24 January 2014
Date of Publication: 12 March 2014
Inspection Report published 12 March 2014 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 23 January 2014 and 24 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 and talked with staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We also spoke with external healthcare professionals.

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. Information was not available for the use of all “as required” medicines.

Reasons for our judgement

At our last inspection on 11, 16 and 19 September 2013, we found the provider was failing to meet this essential standard. We found medicines were not stored safely and appropriately; people were not receiving their medicines as prescribed; the arrangements for obtaining medicines were not robust and put people at risk of not receiving their prescribed medicines.

Following the inspection we took enforcement action and imposed a condition to prevent the provider from accepting any new admissions to the home.

At this inspection we found medicines were stored securely and the controlled drug cabinet was locked. However, people were at risk of not receiving their medicines safely and when they required them.

We looked at a sample of 12 medication administration record (MAR) charts. The printed MAR chart for one person showed they were prescribed an eye drop to be administered once at night. We saw changes had been made to the handwritten MAR chart, for the person to receive this eye drop twice a day. Staff told us they did not have a copy of this person’s prescription and they could not tell us who had changed the MAR chart or when this had occurred. This meant the person was at risk of receiving medicines inappropriately and not according to their prescription. Guidance issued by the Royal Pharmaceutical Society “The handling of medicines in social care” had not been followed. If a new prescription had been issued, this should have been available; if a verbal instruction had been given by the GP, then a record of the changes should have been made, including details of the staff member who received the new instructions.

Another person’s medication, which was an “as required” sedation, was found in the medicines trolley. However, the person’s MAR chart record did not include this medicine. We received conflicting reports from staff as to whether this person was currently prescribed this medicine. We asked to see the prescription for it, but this was not available. The arrangements for obtaining medicines were not robust. And put this person at risk of not receiving their medicines when they required them. A senior staff member told us they would seek advice to resolve the issue.

Staff had been asked by the community mental health team to monitor and record the effect of medication prescribed to a person to manage their agitation/behaviour issues. Records for January 2014 showed the person’s behaviour had only been recorded on two days. This meant mental health specialists would not be able to monitor the effectiveness of this medication, and adjust the dose appropriately, in order to meet this person’s needs.

We found there were three people who were self-administering their prescribed inhalers. A staff member told us this required a certain level of dexterity and cognition to be able to administer them safely. However, they said no assessments had been carried out to ensure these people were able to manage their medicines safely and effectively. There were no care plans in place to identify the level of support and monitoring required; there were no records to show the date or quantity of inhalers dispensed; and staff told us they did not carry out checks to ascertain the frequency with which people were using the inhalers. Appropriate arrangements were not in place to ensure people were able to self-administer this medication safety.

The records for the administration of creams and ointments were not adequate and the provider could not be assured people were receiving their creams as prescribed. Most of the people using the service were prescribed Cavilon cream, which acted as a barrier against body fluids for the prevention of skin irritation from incontinence. The MAR charts showed there were numerous gaps and staff could not tell us whether people had had their creams applied. One person was prescribed a cortisone based cream, but their MAR chart showed they did not receive this cream for two consecutive days. Ano