You are here

Archived: The Oaks Nursing Home

All reports

Inspection report

Date of Inspection: 8, 9 May 2012
Date of Publication: 20 July 2012
Inspection Report published 20 July 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.

A change in circumstances within the home means there is no risk to people in respect of the management of medicines.

User experience

We spoke to people who lived at the service but their feedback did not relate to this standard.

Other evidence

The supplying community pharmacist had visited the service on 26 April 2012. They checked the safe handling of medicines. They told us they had made recommendations and areas for improvement to ensure that people’s medicines were handled safely. The acting manager told us that some of these recommendations had been completed.

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

Medicines in the medicine trolley were stored neatly and in an organised manner which made it easy to locate people’s medicines.

Medicines requiring refrigeration were stored in a separate locked refrigerator. The temperatures of the refrigerator were recorded daily and were within the safe storage temperature range for medicines. There were no room temperature records available. We saw that the temperature of the room was within the safe storage temperature range for medicines. The acting manager told us she would ensure daily room temperature checks were recorded. This meant that arrangements were in place for the safe storage of people’s medicines.

We did not find there were Appropriate arrangements in place to ensure that stock checks could be done. We found a form used by the service for checking medicines dated April 2012. There were no checks made on the stocks of medicines or if medicines were given to people as prescribed. We saw records for the receipt of people’s medicines but the dates of opening of medicines were not always recorded and any extra medicines available at the end of a month were not carried forward to a new month. The community pharmacist visited on 26 April 2012 and also recommended improvements should be made in this aspect of medicines management. We looked at one person’s medication administration record (MAR) chart. We were unable to make checks on two prescribed medicines and could not determine if the medicines had been given as prescribed. This meant that it was not always possible to check if people had been given their prescribed medicines.

We found the records of refusal of medication were not always clearly documented. Staff were documenting when medicines were not given onto the MAR charts but the codes that were used did not match the codes provided by the supplying pharmacy. This meant that staff were not following correct procedure and this made it difficult to know why a person had not been given their prescribed medicine.

Personal care plans relating to people’s medicines and management of medicines were not always current or kept up to date. We looked at two care plans. One person was prescribed a medicine to be given when required. There was no person centred information or guidance to explain the circumstances in which it would be necessary to give the person the prescribed medicine. When we asked staff for more information they were able to tell us but this was not recorded in the person’s care plan. It is important for people who cannot communicate verbally that this information is available. One person was prescribed a medicine which required careful monitoring. The available information in the care plan stated that checks were required every week. The records showed that these checks were not being recorded every week. We were told that the doctor had changed the checks to be made once a month. This information was not documented in the person’s care plan. We were told by the service that they were in the process of updating all care plans.

There were no arrangements to ensure that medicines given covertly had been assessed in accordance with the Mental Capacity Act 2005. Covert administration of medicines is when medicines are administered in a disguised form without the knowledge or consent of the person receiving them, for example, in food or in a drink. Whilst looking at one person’s care plan we found a recorded entry dated 28 January 2012, which stated the person was being