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Inspection report

Date of Inspection: 5 December 2012
Date of Publication: 31 January 2013
Inspection Report published 31 January 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 reviewed all the information we have gathered about Leighton Hospital, looked at the personal care or treatment records of people who use the service, reviewed information sent to us by the provider and carried out a visit on 5 December 2012. We observed how people were being cared for, talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

The service did not fully protect people against the risks associated with the unsafe use and management of medicines as the hospitals arrangements for medicines handling and recording were not consistently adhered to.

Reasons for our judgement

We spoke with six patients on three wards about their medicines. Most people we spoke with were positive about their stay, however, Trust staff had recently identified some concerns about medicines handling on one ward. They told us how this was to be progressed through the hospitals error reporting procedures, so appropriate action could be taken. We found that the prescription charts were generally clearly presented but codes for recording the reason why doses of medication were not given were not consistently used.

We looked at how medicines were handled and saw appropriate arrangements were in place for confirming and reviewing people’s medicines on first admission to hospital. When patients were admitted to the hospital doctors recorded and prescribed their medicines following a standard procedure. This was then checked by the pharmacy team within 24 hours to make sure all the information was correct.

People we spoke with had enough information about their medicines. One person told us they received “good care” and told us that doctors had explained about the medicines they were taking, and why. A second person told us “sometimes my medicines looked different, but I asked the nurses and they explained it was just a different brand”. Two people confirmed that their pain was well managed, however, when we approached one patient they told us they were in pain. The lunchtime medicines were due but we saw that the actual time the last dose of painkiller had been administered was not recorded, so it was not possible to tell whether another dose could have been given slightly earlier. Records of medicines given to people on discharge were clear. Nurses in the discharge suite went through people’s medicines with them to help ensure they knew how to take them, before they went home.

The hospital wards had a regular clinical pharmacy service. We saw evidence of regular medicines audits that helped identify weaknesses so that any necessary improvements could be made. Concerns had been identified about medicines handling on one of the wards we visited and this included one example of missing a dose of a medicine included on the hospitals list of medicines that should never be missed. The Trust had picked up these concerns through their monitoring. We were told us how this was to be progressed through the hospitals error reporting procedures, so appropriate action could be taken.

We looked at medicines record keeping. Appropriate arrangements were in place in relation to the recording of medicines but were not followed consistently. The prescription charts we looked at were generally clearly presented, however, on three of the seven charts we looked at the reason for missed doses had not been recorded using the chart key. We also saw one example where the actual dose of an injection prescribed with a dose range was not recorded. Clear records showing the treatment people have received are important when carrying out reviews. However, we saw one record that showed a medication had been increased from twice, to three times daily when the patient was currently refusing to take it. The rationale was not recorded and there were no records to show whether any alternatives had been considered.

We found that medicines were safely stored. An audit of the storage and security of medicines carried out by The Trust in October 2012 had identified some concerns but action had been taken to address these. Controlled drugs were properly recorded and checked. However, on one ward there were unwanted controlled drugs that needed to be removed by pharmacy. Emergency medicines were available on the wards but the daily checks had not been completed for the previous day on two of the wards we visited. These checks are important to ensure that everything is at hand, should it be needed.