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Inspection report

Date of Inspection: 3 January 2013
Date of Publication: 24 January 2013
Inspection Report published 24 January 2013 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

We looked at the personal care or treatment records of people who use the service, carried out a visit on 3 January 2013, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

Our judgement

People were not protected against the risks associated with medicines because the provider had inappropriate arrangements in place to manage medicines.

Reasons for our judgement

We spoke with two people about their medication. They told us “I have never run out of medication, they always get it for me.” Another said “They (the staff) will sort out my medication for me if I am going out for the day.”

We saw that people who managed their own medication had an appropriate risk assessment in their care plan. People’s current medication was listed within their Medication Administration Record (MAR). The provider may like to note however, for people who required assistance with taking their medication, we did not see that they had been consulted about how they preferred to take their medication. This meant that people’s choice may not have been respected.

Since the inspection, the provider has confirmed that all people using the service have a medication risk assessment in place containing details of how people wish to have their medication administered.

Staff we spoke with told us that they all administered medication but that certain medications such as warfarin could only be given by more senior staff. We saw that they had all been trained in medication management by the local pharmacist. Monthly checks were made by the management team to ensure that staff remained competent.

We saw that there was a policy that described the process for the ordering, supply, receipt, storage, recording, administration and disposal of medication. This also commented on controlled drugs and covert administration. Staff told us that they had read the policy and we saw evidence that they had signed to say that this had happened. However, prior to the inspection we were made aware of an incident where medication had not been given as prescribed. We saw that new processes had been put in place to improve the management of medication, but it was too early to assess whether these were effective.

We observed a medication round. We saw that people were approached in a kind manner and their consent was gained before the medication was administered. However, the provider may like to note that people were not given information about what they were taking. This meant that people may not have understood why they were taking the medication.

Since the inspection, the provider has confirmed that the prescribing of medication is discussed between the individual and their General Practitioner (GP) and that staff are aware of this information. To assist them with this, they have access to a central file that identifies medicines, why they would be prescribed and any associated side effects.

We saw that audits in respect of medication were performed on a monthly basis. There was also a daily checklist in place that enabled staff to monitor that people had received their medication at the appropriate time. However, we found discrepancies in four out of six medication records when we compared them with quantities of medication that remained in stock. The manager was unable to account for this discrepancy. We also found there were some omissions in one record for the administration of medicines. When we asked the staff member why this was they said this was an error and retrospectively completed the record. This was poor practice and meant that we could not be assured that medicines had been administered as prescribed and intended by the prescriber. We were advised by the manager that an audit by an external pharmacist had been arranged to take place in January 2013.