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Archived: Eleighwater House Retirement Home Good

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Inspection report

Date of Inspection: 7 November 2013
Date of Publication: 28 November 2013
Inspection Report published 28 November 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 7 November 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 did not have appropriate arrangements in place to manage medicines.

Reasons for our judgement

There was suitable secure storage in the home for medication. Medicine was only administered by the providers and one other member of staff. Other staff that we spoke with said they had never been asked to administer medication.

People told us that they got their medication at the right time but one person said “I sometimes have to remind them to give me my tablets.” We looked at this person’s medication chart and noted that their medication was prescribed to be taken at different times to the other people who lived at the home. On the day of the inspection we saw that this person received their medication at the prescribed time.

Medication was not always administered in line with good practice guidelines which could place people at risk of receiving the wrong medication. The Royal Pharmaceutical Society guidelines stated; ‘In order to give a medicine safely, you need to be able to: Identify the medicines correctly. To do so, the medicine pack must have a label attached by the pharmacist or dispensing GP.’

The medication for four of the five people who lived at the home was dispensed from the pharmacy in a labelled monitored dosage system. The fifth person’s medicine was dispensed in individual labelled packets. The provider was dispensing this medication into an unlabelled monitored dosage tray to be administered at a later time. This was secondary dispensing and could lead to accidental mix up and errors.

There were some errors in the recording of medication. We looked at the medication administration records for all five people who lived in the home. We saw that in one instance there was no signature to state that a tablet had been given to the person. We checked this person’s medication and noted that it was not in the box for the day in question. Another person’s medication chart stated that the medicine should be given twice a day but it had only been signed as being administered once a day. These errors in the recording of medicines given meant that there was no clear audit trail and no way to check the amount of medication in the home.

The dispensing pharmacy supplied printed medication administration charts. Where the provider needed to hand write additional prescribed medicines onto the charts these had not been signed or checked by a second person. Checking by a second person would reduce the risks of incorrect entries onto the medication administration records.