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Inspection report

Date of Inspection: 29, 31 May 2013
Date of Publication: 29 June 2013
Inspection Report published 29 June 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 29 May 2013 and 31 May 2013, 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, talked with staff, were accompanied by a pharmacist and reviewed information sent to us by other authorities. We talked with other authorities.

Our judgement

The provider did not have the appropriate arrangements in place to ensure that people were protected against the risks associated with the unsafe management of medicines.

The provider was failing to meet Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Reasons for our judgement

We used a number of different methods to help us understand the experiences of people using this service. We talked to staff and looked at storage and record keeping of medication. We also talked to two people who used the service about their medications.

We saw that one person was able to take their own medicines. There was a risk assessment in place to monitor their compliance and we read that this was currently under review because non-compliance had been identified. Another person we spoke to was administering some of their medicines and there was no risk assessment in place.

Medicines were stored appropriately. We observed no medicines stored in the office and in the two flats we visited we saw that people had lockable cupboards and their medicines were stored securely.

Appropriate arrangements were not always in place in relation to the recording of administration of medicines. All people being supported with their medicines had printed Medication Administration Records (MAR). These listed all the medicines which were prescribed and administered by care workers but not those medicines where a person was partly self-medicating. We were told by care workers about one medicine the person was taking but the person said that it had been discontinued. Staff did not have an up to date record and know what the current medicines prescribed were.

The MAR of three people showed that omissions in recording administration were frequently occurring. We could see from the dosage system that they were sometimes given but not signed as given. We were told that people were sometimes away from the service and that they signed a separate leave form in the office when they took their medicines away from the service. We could also see from the daily care notes that medicines were recorded as given. This means that the records made for the administration of medicines were not consistent. Gaps for the administration of medicines on the MAR can present a risk of double dosing a medicine in error, particularly when it is supplied in its original pack and not the dosage system. Two such incidents had already been reported in the service.

We observed that medicines were recorded when received into the service. There was a medicines receipt book and also templates in people's care folders for recording the ordering and receipt of medicines. The disposal book was completed monthly.

The service was still carrying out a rolling monthly audit of all the MAR and daily checks at handover to identify errors and minimise them. The audits were not always identifying poor recording and when it was identified the action taken was not fully recorded.