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Archived: HRGO Recruitment Ltd - Healthcare Division

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Inspection report

Date of Inspection: 21 November 2012
Date of Publication: 13 December 2012
Inspection Report published 13 December 2012 PDF | 94.77 KB

People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)

Not met this standard

We checked that people who use this service

  • Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential.
  • Other records required to be kept to protect their safety and well being are maintained and held securely where required.

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 21 November 2012, checked how people were cared for at each stage of their treatment and care and talked with people who use the service. We talked with staff.

Our judgement

People were not protected from the risks of unsafe or inappropriate care and treatment, because accurate and appropriate records relating to the administration of medicines had not been maintained.

Reasons for our judgement

At the time of our visit a personal care service was being provided to approximately twenty people living in their own homes. The majority of people using the service were receiving end of life care and as such, they had been prescribed several different medicines, including controlled drugs. We found that three people, whose care plans stated that they were prompted by staff to take their medicines, were actually being administered the medicines by support staff. This was confirmed in conversation with the three people using the service and a support worker. None of the three care plans had been updated to reflect these changes.

We saw that recording on the Medication Administration Records (MARs) for four people was poor. Medicines in blister packs had been signed as 'administered from the blister pack' with no detail of the medication contained in them. Medicines separate from the blister packs had been handwritten on the MARs, with no strength recorded or frequency of administration e.g. 'Warfarin - take as directed in the little yellow book.' We saw from the records that at some stage this person had been prescribed 1mg and 3mg Warfarin. Staff had signed to say that they had administered it, but there was no record of the dose given to the person.

Bound books were used to record medication and support workers' notes. Because some people were on many different types of medicines, staff were often running out of space in the books, so they had begun to write medication records on any space available. Consequently, it was impossible to determine if people had received their medicines as prescribed by their doctors.

We saw a number gaps in four people's records, where support workers had not signed to confirm that medication had been given. Because there were no frequencies recorded for when people should take their medicines, it meant there was no audit trail to confirm if people had received their correct medication.

One person was prescribed a controlled drug for pain relief. We saw two entries in the medication records relating to the administration of Oxynorm for pain relief. The two entries queried whether the person was receiving their pain relief in accordance with their GP's instructions. There was no written evidence that either of these concerns had been followed up to determine if the person had been administered their correct medicine. We also saw evidence in the records stating that support staff had left the person's pain relief, either in the fridge, or on a table, for the person to take later. There was no assessment of risk in the person's care plan to ensure that it was safe to do this.

We found several examples of 'as required' medicines being administered to three people using the service. The registered manager confirmed that they did not have any guidelines in place to ensure that people were administered these medicines in line with the recommended maximum doses.

The service's medication policy and procedures gave clear guidance for good practice in the safe administration of medicines. However, it was clear that support staff and management were not following their own policy and procedures. This was pointed out to the registered manager during the inspection, as were all the other concerns with medication recording that we found. The manager and coordinator confirmed that the review and updating of all care plans, for people receiving support with their medication, would be given priority