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Archived: Kalcrest Care Ltd

This service was previously registered at a different address - see old profile

The provider of this service changed - see new profile

All reports

Inspection report

Date of Inspection: 10, 11, 16 April 2013
Date of Publication: 17 May 2013
Inspection Report published 17 May 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 10 April 2013, 11 April 2013 and 16 April 2013, talked with people who use the service and talked with staff. We were accompanied by a pharmacist.

Our judgement

The provider had appropriate arrangements in place to manage medicines.

Reasons for our judgement

Our inspection on the 8 November 2012 found we had concerns the medicine records did not provide enough information to enable staff to administer medication safely. The provider wrote to us and told us they would take action to ensure they were compliant with these essential standards. They told us these actions would be completed by the end of February 2013.

We visited two people who used the service in their homes, at times when their care workers were with them. Both of these people showed us their medicines and care records. We found these were accurate and up to date.

At the inspection on the 8 November 2012 we found where people's medications were stored in and administered from a dosset box (This was a box with separate pots, which contained all the medication given at a specific time and day which was dispensed by the pharmacist). The instruction on the medication administration record sheet (MARs) was 'dossett box'. It did not list the medication in the dossett box or the time it should be administered. At this inspection we saw that a new medicine administration record was started each month for all medication and the care staff or normally their supervisor, wrote the medicine name and dose instructions on the new chart.

At the inspection on the 8 November 2012 we saw there was a lack of specific information for staff in people’s care records to inform them about what help people needed to take their medicines. At this visit we spoke to the director, manager, co-ordinator and two supervisors and two support staff in people’s homes. We looked at the agency’s medicine policy and more care records. We saw the help people needed to take their medication was clearly described in their support plans. All the staff (including the two care staff we met in people’s homes) described the different levels of support the agency offered with medication clearly and in the same way. Although we found staff were administering the correct medication the provider may find it useful to note, the staff found the new policy confusing and what they said differed from the information in the medicine policy that had recently been re-issued to all staff.

At our inspection on the 8 November we found the medication administration records (MARs) showed the person was prescribed aspirin but it did not state the dose, or the time it should be given or how often. During this inspection we looked at some people’s medicine records for February and March 2013. We saw that each medicine was listed on the chart. However we saw some of these systems had not embedded themselves fully. This meant that there was discrepancy with the records for example although we found staff had acted correctly and one person had been helped to take their medicine once and this was correct. The signatures on one person’s chart said that a medicine had been taken twice a day for a period of time. We found wrong instructions on how to help another person take their medicines in their care plan. Also there was a further discrepancy which was caused by a break down of communication where a person was prescribed a medicine to thin their blood, and the dose of this tablet had been changed by the prescriber. However this information of the dose change was not available to staff for two days because the information had been put in the post box and they had to wait for the relative to visit to gain access.

Although we saw people had received the correct medication we found that there continued to be some gaps in the medication records and this had not been identified by the systems the service used to assess and monitor the quality of the service they provided.