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Assisting Service Users with Medication Policy

1. Purpose

At {{org_field_name}}, we are committed to ensuring that all service users receive the right medication, at the right time, and in the right way. This policy provides clear guidelines for our staff on how to assist service users with medication safely, legally, and in line with best practices.

This policy is intended to ensure that medicines support in supported living is safe, person-centred, proportionate, and promotes independence. It applies to all levels of medicines support, including prompting, assistance, administration, ordering, collection, transport, storage, recording, disposal, escalation of concerns, and review of medicines support arrangements.

The objectives of this policy are to:

• Ensure compliance with the Health and Social Care Act 2008, CQC Regulations, and NICE Guidelines.
• Support service users in maintaining independence while ensuring their safety when taking medication.
• Define staff roles and responsibilities in the safe handling and administration of medication.
• Prevent medication errors through clear procedures and training.
• Establish robust record-keeping and reporting systems.

2. Scope

This policy applies to all employees, bank staff, agency staff, temporary workers, managers, and any other persons authorised by {{org_field_name}} to support adults with medicines in supported living services in England.

It applies where staff provide any medicines-related support, including:

• prompting or reminding a person to take medicines;
• assisting a person to access or prepare their medicines;
• administering medicines;
• ordering, collecting, receiving, transporting, storing, recording, auditing, and disposing of medicines where this is part of the agreed support package;
• supporting prescribed, non-prescribed, over-the-counter, topical, inhaled, liquid, controlled, refrigerated, and ‘when required’ (PRN) medicines.

This policy must be read alongside the individual’s care plan, medicines support plan, risk assessments, MAR/eMAR, consent documentation, Mental Capacity Act assessments where relevant, and any service-specific procedures.

3. Legal and Regulatory Framework

This policy is informed by and must be implemented in line with the following legislation, regulations and guidance:

• Health and Social Care Act 2008
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including:
  • Regulation 9: Person-centred care
  • Regulation 11: Need for consent
  • Regulation 12: Safe care and treatment
  • Regulation 13: Safeguarding service users from abuse and improper treatment
  • Regulation 17: Good governance
  • Regulation 18: Staffing
  • Regulation 20: Duty of candour
• Mental Capacity Act 2005 and associated Code of Practice
• Medicines Act 1968
• Misuse of Drugs Act 1971 and associated controlled drugs requirements
• NICE Guideline NG67: Managing medicines for adults receiving social care in the community
• NICE Quality Standard QS171: Medicines management for people receiving social care in the community
• Current CQC guidance on medicines in adult social care, including supported living, MAR records, medicines care plans, PRN medicines, covert administration, and staff training and competence.

4. Levels of Medication Support

Staff must only provide the level of medicines support that has been assessed as necessary, agreed with the person, recorded in the care plan and medicines support plan, and for which the staff member has been trained and assessed as competent.

Medicines support must always be delivered in the least restrictive and most independence-promoting way.

4.1 Prompting

Prompting means reminding or encouraging a person to take or use their medicine themselves. Staff must not physically handle the medicine unless the care plan authorises a higher level of support. Staff must record that prompting was offered and whether the person then took, refused, or was unable to take the medicine.

4.2 Assistance

Assistance means helping a person who can self-administer but cannot manage all practical aspects unaided, for example opening packaging, reading labels, selecting the correct medicine container, or preparing equipment. The person must remain in control of the decision to take the medicine and, wherever possible, take or apply the medicine themselves.

4.3 Administration

Administration means the staff member selects, prepares, and gives or applies the medicine to the person in accordance with the prescriber’s directions and the person’s care plan. Administration may only be carried out by staff who are trained, authorised, and currently assessed as competent.

4.4 Self-administration and risk enablement

The service will support self-administration wherever this is safe and consistent with the person’s wishes. Any decision that a person self-administers all or part of their medicines must be supported by an assessment of risks, the person’s capacity, required reasonable adjustments, storage arrangements, and the level of staff monitoring needed.

4.5 Review of level of support

The level of medicines support must be reviewed promptly if there is a change in capacity, health condition, dexterity, communication, cognition, medicine regimen, risks, incidents, refusal patterns, hospital discharge, or professional advice.

5. Process for Assisting Service Users with Medication

5.1 Before providing medicines support

Before any medicines support is given, staff must:

• check the current care plan, medicines support plan, MAR/eMAR, risk assessments, allergy status, and any specific instructions;
• confirm the person’s identity using the service procedure;
• check the medicine label, prescription directions, expiry date, and storage requirements;
• confirm the person’s consent, or where relevant confirm that any best-interest process under the Mental Capacity Act has been completed and recorded;
• make sure the medicine has not already been given;
• check for any recent changes to the medicine, dose, formulation, route, or timing;
• prepare a clean, safe, and appropriately private environment;
• seek advice before proceeding if there is any discrepancy, unclear instruction, damaged packaging, missing medicine, omitted signature, or concern about the person’s condition.

5.2 During medicines support

Staff must follow the 6 Rs of safe administration and any service-specific competency guidance. Staff must:

• support the person in a calm, respectful, and person-centred way;
• explain the medicine in a way the person can understand;
• support independence wherever possible;
• observe administration sufficiently to be satisfied the medicine has been taken, applied, inhaled, or otherwise administered as intended, where appropriate to the medicine and the agreed support level;
• record immediately after administration or attempted administration;
• record refusals, omissions, variable dose decisions, PRN administration, or any problem encountered;
• escalate immediately where the person appears unwell, experiences side effects, refuses essential medicines repeatedly, or where a medicine error may have occurred.

5.3 After medicines support

After medicines support is provided, staff must:

• complete the MAR/eMAR and any additional notes at the time of support;
• record the exact reason for non-administration, refusal, delay, or partial administration where relevant;
• monitor the person for expected effect, side effects, or adverse reactions where required;
• return medicines promptly to safe storage;
• dispose of associated waste safely;
• report and document any concern, discrepancy, error, or near miss in line with the incident procedure.

5.4 Refusal of medicines

A person with mental capacity has the right to refuse medicines, even if staff or others consider that decision unwise. Staff must not coerce, mislead, or conceal medicines from a person with capacity.

Where a person refuses a medicine, staff must:

• respect the refusal;
• record the refusal clearly on the MAR/eMAR and in daily notes where appropriate;
• offer explanation and reassurance without pressure;
• follow any medicine-specific care plan instructions;
• escalate repeated refusals, refusals of time-critical or essential medicines, or any associated deterioration to the line manager and relevant healthcare professional in line with the escalation procedure.

Where there is doubt about a person’s capacity to decide about a medicine, staff must refer the matter for assessment and act in line with the Mental Capacity Act 2005.

5.5 PRN (‘when required’) medicines

PRN medicines must only be given in accordance with the prescriber’s instructions and the person’s individual PRN protocol or care plan.

The PRN protocol/care plan must include:

• the name of the medicine and the condition or symptoms it is intended to treat;
• the circumstances in which it should be offered or administered;
• the dose, route, frequency, and maximum dose in 24 hours;
• the minimum interval between doses;
• any non-medicinal alternatives to try first where appropriate;
• what to monitor after administration;
• when staff must seek medical advice or urgent help.

Staff must record the reason for giving the PRN medicine, the dose given, the time given, and the outcome/effect where appropriate.

5.6 Covert administration of medicines

Covert administration means giving medicines in a disguised format without the person’s knowledge or consent. This must never be used for a person who has mental capacity to decide about that medicine.

Covert administration may only be considered where:

• the person is assessed as lacking capacity for the specific decision about the specific medicine;
• the medicine is necessary for the person’s health or wellbeing;
• all less restrictive options have been considered and found unsuitable;
• a best-interest decision has been made in line with the Mental Capacity Act 2005;
• the decision is clearly documented in a medicine-specific management plan, with advice from the prescriber and pharmacist where required.

The need for covert administration must be reviewed for each medicine separately and reviewed again whenever medicines change, doses change, or circumstances alter.

6. Handling Medication Safely

6.1 Ordering, collection and receipt

Where the service is responsible for ordering, collecting, receiving, or transporting medicines, this must be clearly agreed in the person’s care plan. The service must maintain a clear audit trail showing what was ordered, collected, received, and handed over.

6.2 Storage

Medicines must be stored safely in the person’s own home in a way that maintains security, dignity, independence, and the manufacturer’s storage requirements. This includes medicines requiring refrigeration and controlled drugs.
Supported living services do not require a separate central medicines fridge or controlled drugs cupboard solely because they support people with medicines. Storage arrangements must be based on the individual person’s needs and risk assessment.

6.3 Controlled drugs and higher-risk medicines

Controlled drugs and other higher-risk medicines must be subject to additional risk assessment, secure storage arrangements appropriate to the person’s home, accurate records, prompt discrepancy reporting, and any additional monitoring required by the prescriber or pharmacist.

6.4 Medicines administration records (MAR/eMAR)

MAR/eMAR records must be legible, clear, accurate, up to date, completed as soon as possible after support, and include medicines administered, omitted, delayed, refused, or otherwise not taken as intended. The reason for any non-administration must be recorded.

6.5 Errors, near misses and incidents

Any medicines error, near miss, discrepancy, missing medicine, wrong dose, wrong person, omitted dose, late dose, incorrect recording, or storage failure must be reported immediately to the manager. Staff must take urgent action to protect the person, seek clinical advice where needed, inform the person and relevant others in line with the duty of candour and consent/confidentiality requirements, and complete all required records and notifications. Investigations must identify root causes and learning.

6.6 Disposal

Medicines must not be disposed of in household waste unless this is explicitly permitted for that product. Unwanted, discontinued, or expired medicines should normally be returned to a community pharmacy for safe disposal. Where the provider transports or disposes of medicines, a risk assessment and disposal record must be kept, including the date, medicine name, quantity, destination, and staff member involved.

6.7 Transfer between settings and changes to medicines

The service must have arrangements to make sure accurate and up-to-date medicines information accompanies the person when they move between services, attend hospital, or return from hospital. Any change to medicines must be verified and updated promptly in MAR/eMAR, care plans, and risk assessments before the change is implemented, unless urgent clinical circumstances require immediate action.

7. Training and Competency Assessment

All staff who support people with medicines must receive training appropriate to their role and the tasks they undertake. Training alone does not authorise a staff member to support or administer medicines.

Staff must not manage or administer medicines until they have been assessed as competent for the specific medicines support tasks they will perform.

{{org_field_name}} will maintain a formal process for:

• induction and medicines training;
• supervised practice where required;
• competency assessment by a competent assessor;
• annual review of medicines knowledge, skills, and competencies, or sooner if concerns arise;
• additional assessment following incidents, role changes, prolonged absence, or changes in the medicines support tasks performed.

Records of training and competency assessments must be kept, monitored, and reviewed.

8. Consent, Mental Capacity and Record-Keeping

Consent must be sought before medicines support is provided. Care and treatment must only be provided with the consent of the relevant person, except where the law allows otherwise.

Where a person may lack capacity to make a decision about their medicines, staff must act in accordance with the Mental Capacity Act 2005 and the associated Code of Practice. Capacity must be considered decision-specifically and time-specifically.

The service must maintain secure, accurate, complete, contemporaneous, and accessible medicines records, including:

• medicines support care plans;
• MAR/eMAR records;
• risk assessments for self-administration, storage, transport, or disposal;
• allergy information and sensitivities;
• consent and capacity/best-interest records where relevant;
• PRN protocols;
• records of medicine changes;
• incident, error, and near miss reports;
• disposal records;
• training and competency records.

Records must be reviewed regularly and updated promptly whenever a person’s medicines, support needs, risks, capacity, or preferences change.

8.1 Medicines support care plans

Every person who receives medicines support must have an individual medicines support care plan. This must set out:

• what medicines support the person needs and why;
• what they can do independently;
• what staff must do, and what staff must not do;
• preferences, communication needs, and reasonable adjustments;
• allergies and known adverse reactions;
• support for specific formulations, for example inhalers, creams, eye drops, patches, liquids, or refrigerated medicines;
• arrangements for ordering, collection, storage, recording, and disposal where these are part of the support package;
• action to take if the person refuses, misses, vomits, spills, or cannot take the medicine;
• professional contacts and escalation arrangements.

The plan must be person-centred, regularly reviewed, and updated whenever medicines or support needs change.

9. Complaints and Concerns

Service users and their families can raise concerns about medication assistance at any time.

Complaints will be investigated promptly, and appropriate action will be taken.

Medicines-related concerns, complaints, discrepancies, or safety issues must be taken seriously, recorded, investigated, and used to improve practice. Where a concern involves possible harm, abuse, neglect, a medicines error, or repeated failure in medicines support, the matter must also be considered under safeguarding, incident reporting, duty of candour, and regulatory notification procedures where applicable.

Where to complain:

1) Verbally to the Registered Manager or Safeguarding Lead

2) Inform the Registered Manager by email: {{org_field_registered_manager_email}}

3) Call the office and inform the Registered Manager or Safeguarding Lead: {{org_field_phone_no}}

4) Out of hours phone number: {{out_of_hours}}

5) Online via our website: {{org_field_website}}

For more information about how to raise a complaint please visit “Receiving and Acting on Complaints Policy”

10. Policy Review

This policy will be reviewed at least annually and earlier where required by changes in legislation, regulation, NICE guidance, CQC guidance, medicines practice, National Patient Safety Alerts, incidents, audit findings, inspection feedback, or learning from complaints and safeguarding concerns.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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