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Inspection report

Date of Inspection: 16 October 2013
Date of Publication: 13 December 2013
Inspection Report published 13 December 2013 PDF

People should be given the medicines they need when they need them, and in a safe way (outcome 9)

Meeting 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 16 October 2013, observed how people were being cared for and talked with people who use the service. We talked with staff and took advice from our pharmacist.

Our judgement

The provider did have the appropriate arrangements in place to ensure that people were protected against the risks associated with the unsafe management of medicines.

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 three people who used the service.

We saw that two people were able to take their own medicines and there were risk assessments in place to monitor their compliance. We looked at the monitored dosage system for one person and saw that some tablets had not been taken and others had been taken early. We discussed this with the manager who told us that they would discuss compliance issues with the family of the person as they were also actively involved in the person's care.

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

Appropriate arrangements were 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 and for those people who were self-medicating.

The MAR of four people showed just one omission in recording administration. We could also see that other medicines were not given at the same time as the person was recorded as being asleep. We saw that when people were away from the service that the MAR was signed appropriately. We could also see from the daily care notes that medicines were recorded when they were given.This means that we could be assured that people had received their medicines as prescribed.

We observed that medicines were recorded when received into the service. When we audited two medicines, one could not be reconciled and the provider may like to know that records were untidy and unclear when made in the middle of a medication cycle. The disposal book was completed monthly.

The service was still carrying out rolling daily audits of all the MAR to identify errors and minimise them.The manager was also carrying out weekly audits as indicated in the action plan. The audits were identifying poor recording but not always the action taken and the service may like to know that the audits did not always detail sufficiently the actual error or concern identified and the action taken.

We saw that for one person due to have a diagnostic procedure as a day patient in hospital, they did not have two of their medicines for four days. There was no reason stated on the MAR chart and when we asked the provider why, we were told that they had been told to omit them for 4 days. We could find no written evidence of this conversation and the provider told us after the inspection that they had put new procedures into place so that only written orders and instructions involving medication were acceptable.