You are here

Archived: Avonwood Manor Home Care Angels

All reports

Inspection report

Date of Inspection: 20, 28 January and 3 February 2014
Date of Publication: 5 March 2014
Inspection Report published 05 March 2014 PDF | 79.62 KB

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 20 January 2014, 28 January 2014 and 3 February 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.

Our judgement

People were not 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 found that the agency did not have appropriate arrangements in place in relation to the recording and administration of medicines.

We looked at the agency's medication policy and procedures. However the policy did not fully comply with regulation 13 of the Health and Social Care Act 2008 (Regulated Activities 2010) and it did not reflect national published guidance about how to ensure medicines were handled, stored and administered safely, or relevant local authority policies.

During our inspection we found that Medication Administration Records had been handwritten or typed by care workers. These records had not been signed by the person creating the record nor had they been checked and signed by a second person. We also found that newly prescribed medicines had been handwritten onto medication records and these entries had also not been signed and checked and signed by a second person. Most of the entries were only the name of the drug and the full information on the prescription label had not been transferred to the record. This meant that people may not have received their medicines as prescribed and there was no system to check for errors.

In addition we found that some people had been prescribed medication on an "as required" basis. There was no assessment or care plan to guide care workers on when to administer medication, how much to give, or the maximum amounts to be given within a fixed period. We also found that some people had medicines which were to administered in variable doses. There was no assessment or care plan to inform care workers what amount should be given and administration records did not always clearly show how much had been administered.

We found information in a care plan for one of the people that we tracked that they had allergies to certain medicines. This information had not been transferred to the medication administration records. This meant that people were at risk of receiving medicines that they were allergic to as there was no warning for care workers.