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Highbarrow Residential Home Requires improvement

The provider of this service changed - see old profile

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Inspection report

Date of Inspection: 24 December 2012
Date of Publication: 19 January 2013
Inspection Report published 19 January 2013 PDF | 72.74 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 24 December 2012, 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 and talked with staff.

Our judgement

People were not fully 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 arrived at Highbarrow Residential Home at 7:30 am. On our last inspection in October 2012 we arrived at 6:40 am. We had found the office was unlocked and we saw that ten people’s morning medication had been dispensed into medication pots that were not labelled. This meant the staff were dispensing medicines which were not identifiable in any way and placed people at risk of receiving the wrong medicine.

On this inspection we checked the office, which was still unlocked, but found that no medication was on view. The service had secure storage for medication and we saw this was being used. This meant that improvements had been made, and medicines were locked away as required.

On the last inspection we saw one loose tablet on top of the office filing cabinet. We had asked the registered manager about this but they were not aware a tablet had been placed there. This meant the home could not be assured people had been given their medication as prescribed and medication was not being stored safely.

On this inspection we saw evidence to confirm an investigation had taken place regarding this, but the registered manager had been unable to find out why the tablet was there. We saw a record in the returns book to show the mediation had been returned to the pharmacy as required. This meant the registered manager had taken the appropriate steps to try to ascertain what had happened and they had disposed of the medication correctly.

On the last inspection we looked at the medication record for one person who had ‘as and when required’ (PRN) medication and saw that a protocol was not in place. These should be available and demonstrate the decision making processes for PRN medication and validate when medicines are administered. Providing a protocol ensures the staff have clear information on why and when to provide certain medication.

On this inspection we saw that information regarding PRN medication had been included within the home’s medication policy. However, further improvement was needed because we saw medication records for two people that had not been clearly signed off by the staff because they had used the wrong code. We noted that information on the MAR was in some instances ambiguous or recorded ‘as prescribed’ but staff did not always have clear instructions to follow because it did not state what ‘as prescribed’ meant.

We observed two people’s medicines being dispensed at breakfast time. The member of staff administering the medication was seen to ask people how they were feeling and people were not rushed. People who were able to take their own medication were handed their medicines in a dispensing pot. This meant people were encouraged to take their own tablets where possible.

We asked the registered manager if people using the service administered any medications themselves. We were informed some people did. These included inhalers and applying prescribed creams. Care records did not offer information on this, and assessments had not been completed to demonstrate safety, consent, capacity or safe storage arrangements. This meant the registered manager had not taken the necessary steps to ensure this was managed in a safe way.

We saw evidence to demonstrate staff who worked in the home during the day were enrolled on a medication course to refresh their knowledge. This meant the registered provider had taken the necessary action to ensure the staff were up to date and suitably trained.

We spoke with the night staff who told us they did not administer medications and therefore did not require the training. Following further discussions we ascertained that on one or two occasions the night staff had given medication to people using the service. These incidents were when people were in pain or had refused to take their medication at the time it was due. This meant the staff had considered people’s needs but were not trained to provide their medication. We discussed this with the registered manager who conf