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Coundon Manor Care Home Good

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Inspection report

Date of Inspection: 9 September 2014
Date of Publication: 25 October 2014
Inspection Report published 25 October 2014 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 9 September 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, were accompanied by a pharmacist and talked with commissioners of services.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Our judgement

People were not protected against the risks associated with medicines because the provider did not always have appropriate arrangements in place to manage medicines.

Reasons for our judgement

Our inspection of 16 June 2014 found poor recording and obtaining of medicines might have resulted in people not being fully protected against the risks associated with medicines.

At this visit, we found appropriate arrangements were in place to obtain medicines. We found the previous issues with the ordering procedure had been addressed by the service. This meant on the day of the inspection we found all prescribed medicines were available for administration. Good procedures for obtaining medicines will ensure that people can have their medicines administered to them when they need them.

At our last visit we saw gaps in the medication administration records (MAR). This meant we could not be sure people had received medicines prescribed by their doctor. During this inspection we looked at 13 medicine administration records. We found the service was able to demonstrate that people had received their medicines as prescribed. Appropriate arrangements for the recording of medicines meant that people’s health and welfare was protected against the risks associated with the handling of medicines.

We found the service had a system for recording the disposal of medicines. We found when comparing the administration records with the disposal records the expected disposal quantity did not always match with the disposal records. This meant the disposal records did not support the service in demonstrating some medicines had been administered as prescribed.

We looked through the records for people who had been prescribed medicines on a 'when required' or 'PRN' basis. We found the records did not have sufficient information to inform nursing staff of how to administer these when required medicines. The lack of information about how medicines should be managed may result in people at the service not getting their medicines when they need them.

Medicines were not always administered safely. We raised a number of issues with the management team about the administration of some medicines when examining the medicine administration records. We found a person using the service had been prescribed an antibiotic medicine that required the administration to take place on an empty stomach, which meant an hour before food or two hours after food. We found the service was not aware of these instructions and as a consequence they had not made any provision to ensure that this medicine was administered as prescribed.

We also looked at a medicine that had been prescribed with specific administration times. We found that the administration times for this medicine were not being adhered to. The poor administration practice placed the health and welfare of this person at risk.

We found the service did not have a system of recording where skin patches used to treat pain and some chronic conditions were being applied to the body. The manufacturers of these patches state in their patient information leaflets that the application of a new patch to the same site should be avoided for a certain period of time. The service was unable to demonstrate that the application of these patches was taking into account the manufacturer’s guidelines thus placing the health and welfare of people using these patches at risk.

Some people had their medicines administered through a tube that went directly into their stomach. We found there was no detailed written information about how to administer the medicines through this percutaneous endoscopic gastrostomy (PEG) tube. When medicines are being administered through this tube we would expect the service to have a written procedure in place. This procedure should describe how to prepare each medicine before it is flushed down the tube and how much fluid should be used to prevent the tube from becoming blocked after the administration of each medicine. The service was therefore unable to demonstrate the administration of medicines in this way was being carried out safely by the staff.

Some medicines were not kept safely.