Derrick Rivers
10 Mar 2014 · Coroner Lisa Hashmi · Manchester (North)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. inadequate drug administration protocol
“the Local Authority and/or CQC, following their recent inspections of the care home, had not noted the inadequacies of the care home's drugs policy/drug administration protocol”
2. incomplete inspection of drug administration system
“not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time”
3. lack of awareness of non‑compliance with drug protocols
“the care home owner and/or manager were purportedly unaware of the fact that carers were not following drugs administration protocols”
4. insufficient audit processes
“the care home had little, if any, audit processes in place”
5. unfit drug administration protocol
“the care home's drugs administration protocol was not fit for purpose and was tantamount to a 'hybrid' of other policies i.e. it was not specific to the care home environment”
6. non‑compliance with pharmacy identification requirements
“the care home's policy did not meet the pharmacy requirements in terms of patient and drug identification (pod system)”
Linked reports
Closely relatedConfidence 0.80 · moderate
This report
“not all CQC Outcomes were considered at the last inspection, purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time”
Later report
“Controlled drugs - the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
Responses
No published response was found on judiciary.uk.