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Archived: Castle Park

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Inspection report

Date of Inspection: 7 January 2014
Date of Publication: 22 February 2014
Inspection Report published 22 February 2014 PDF | 82.58 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 7 January 2014, observed how people were being cared for and talked with people who use the service. We talked with commissioners of services.

We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

Our judgement

Inaccuracies in the recording of medication and inadequate handling of medicines did not ensure people received their medication safely or as required.

Reasons for our judgement

We received information in December 2013 that suggested medication was not being administered properly and that it was being left on tables without ensuring it had been taken by the relevant person. Our observation during the lunchtime meal did not confirm this information but we saw that the person administering the medication touched tablets with their hands without using gloves or any other protective equipment. This means medication is not handled hygienically and poses a risk of cross contamination.

We discussed medication administration procedures with the member of staff who had lead responsibility for medication management. They explained the medication system that the service now operated, which was computerised and left fewer margins for error. For example, it identified the amounts of medicines available and if a medication was being given at the wrong time. We saw people’s allergies were recorded, there were photographs to aid identification and codes were used correctly. We saw an example of covert administration being used and saw the service had obtained confirmation from a General Practitioner regarding this.

We looked at three people's medication records and saw that they were completed accurately in the computerised system. We saw the system highlighted people's allergies, the time span from the last administration of a drug and alerts if there was not a sufficient time span between each administration. However, on one person's chart we saw that the amount of medication recorded for two medicines did not correspond accurately with the stock held. In both cases, there was more medicine available although it had been signed as given. This meant it was unclear whether or not the person had received their medication correctly. We also saw there were daily stock checks undertaken but these had not identified the inaccuracies in the stock balance. This meant that audits were not being used effectively.

We looked at the controlled drugs in use in the service and found that the record was accurate and corresponded with the amount of medicines held.

We saw that the storage of medicines was satisfactory and a random stock check showed that medicines were within their expiry dates. We saw that the medication refrigerator temperatures were recorded on a daily basis and were within safe limits and that medicines with a short shelf life were labelled with the date they were opened.