This report outlines the investigation conducted by the Health Ombudsman into the adequacy of systems in place at Beaumont Care Aged Care Services concerning security of, and access to, schedule 4 and schedule 8 drugs.

On 12 November 2014, the office commenced an investigation into the self-notification by an unregistered provider and also initiated an investigation into the concerns raised about the adequacy of systems in place at Beaumont Care relating to security of, and access to, schedule 4 and schedule 8 drugs.

The scope of the investigation into Beaumont Care was to determine whether:

• adequate policies, procedures and protocols were in place to ensure security, safe storage, restricted access to, and appropriate disposal of schedule 8 and schedule 4 drugs
• staff were compliant with the above policies, procedures and protocols
• Beaumont Care should implement systemic improvements in response to any deficiencies identified above.

On 6 May 2015, a representative of Beaumont Care wrote to the Health Ombudsman in response to the complainant’s allegations and provided the following supporting documentation:

• medication management policy
• medication framework
• Beaumont Care Aged Care Services orientation record
• medication administration competency checklist (RN/EN)
• medication competency test RN/EN
• terms of reference for medication committee
• terms of reference Peninsula Aged Care Service—Quality and Care Governance
• Beaumont Care Aged Care Services audit schedule
• Beaumont Care medication audit—revised February 2015
• copies of previous audits for Peninsula Aged Care Service and Redcliffe Aged Care Service.

After reviewing and analysing the evidence, the Health Ombudsman determined that:

• The investigation conducted by Beaumont Care identified deficiencies in the systems in place with respect to security of schedule 4 and schedule 8 drugs.
• The evidence indicated the unregistered provider exploited these deficiencies to obtain drugs for their own personal use.

Beaumont Care subsequently implemented changes to ensure appropriate medication security. Since the incidents of missing medication were identified, Beaumont Care also underwent Australian Aged Care Quality Agency audits at both facilities and were found to be compliant with all 44 criteria.