Barley View

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Due to the concerns raised to us, we only assessed the 1 quality statement, Medicines Optimisation at this assessment. We found the service did not have safe systems for appropriate and safe handling of medicines. The concerns identified demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

When people were given medicines that required a specified time interval between doses, we saw that time interval was safely observed. Records showed medicines were not always signed as having been administered, therefore the service could not be assured people had been given their medicines as prescribed. When there was an option to give a variable dose, for example 1 or 2 tablets, there was not always information to support staff to know what dose to give, therefore there was risk people might not have received the correct dose. When people were given a ‘when required’ medicine, for example an analgesic, the outcome was not always recorded, therefore staff could not monitor the effectiveness of the medicine and escalate to a prescriber if needed. When people had their medicines covertly, hidden in food or drink, information from a suitably qualified healthcare professional was not always available to ensure their medicines were given safely.

Staff told us they completed medicines training and had their competency checked. The service was working with other healthcare professionals to improve the management of medicines at the home. The service completed audits; however, the audits had not identified all of the concerns found during this assessment. Records showed medicine incidents were being reported; however, the records did not always show what action had been taken following the incident. Therefore, we were not assured staff were informed and able to learn from incidents to prevent them happening again and drive forward improvements.

When people had thickener added to their drinks, to reduce the risk of them choking, this was not always recorded, therefore we were not assured the thickener was added to their drinks as needed, which placed them at a greater risk of choking. When people were expressing feelings or an emotional reaction, and were given a medicine to control or restrain them, the records did not always show what steps the staff had taken to support the person prior to giving the medicine. Therefore, there was a risk people might be over sedated. Medicines were stored within a locked room; however, we saw topical preparations were not always stored securely within people’s rooms so there was a risk they might be inappropriately accessed. The temperature of the medicines fridges were not always monitored daily; therefore, the service were not assured medicines requiring storage in a fridge were being stored at the correct temperature and were safe to use.