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Assisting Service Users with Medication Policy

1. Introduction

Our Home Care business is committed to ensuring that people receive safe, effective and person-centred medicines support in line with the Regulation and Inspection of Social Care (Wales) Act 2016 and the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended), in particular Regulation 58 (Medicines), and Welsh Ministers’ statutory guidance for care home and domiciliary suppliers (2024). We also have regard to relevant medicines and controlled drugs legislation and to current national best practice guidance including NICE NG67 Managing medicines for adults receiving social care in the community and associated Wales resources on medicines support and delegation.

This policy applies to all employees, including Care Assistants, Senior Carers, Coordinators, Managers, and Directors, and provides clear guidance on how we ensure medication is handled correctly and in line with both the service user’s needs and legal requirements. It also provides guidance for CIW inspectors to understand how we manage medication assistance efficiently and within regulatory standards.

2. Key Principles of Assisting Service Users with Medication

• Person-Centred Approach: We support service users in taking their medication in a way that respects their autonomy and preferences.
• Safe Medication Administration: Medication is administered following the prescribed directions and individual care plans to ensure safety and effectiveness.
• Competence of Staff: Only staff who are appropriately trained and assessed for Medication Administration Competency (MAC) are permitted to assist with medication.
• Record Keeping and Documentation: All medication assistance is properly documented in the Electronic Medication Administration Record (eMAR) or paper records as required, ensuring accountability and transparency.
• Agreed level of medicines support: We only provide the type of medicines support that has been assessed, agreed and recorded in the individual’s assessment and personal plan (for example: reminders/prompting; assisting to take medicines; administering from original packs or a monitored dosage system; or delegated clinical tasks). Any change in level of support triggers a review and updated risk assessment.
• Compliance with Medication Policies: Medication management practices comply with regulations and best practice guidelines to ensure service users’ safety and dignity.
• Regular Medication Reviews: Service users’ medication is regularly reviewed by healthcare professionals to ensure that it remains appropriate for their needs.

3. How We Manage Assisting Service Users with Medication Efficiently

A. Medication Assistance Process

We ensure that medication is provided to service users according to the prescribed guidelines and in a way that promotes independence and safety.

For Staff:

• Step 1: Ensure the Medication Administration Record (MAR) is checked against the prescription before administering any medication.
• Step 2: Verify the service user’s identity to confirm they are receiving the correct medication.
• Step 3: Provide medication assistance as per the service user’s needs, whether it’s reminding, prompting, or physically assisting with taking medications.
• Step 4: Where the personal plan requires administration of medicines or any higher-risk support (for example, variable dose medicines, ‘when required’ (PRN) medicines, transdermal patches, anticoagulants, or controlled drugs), staff must follow the specific instructions in the individual’s medicines plan and only undertake tasks they are trained and assessed as competent to perform.
• Step 5: Where a healthcare professional delegates a medicines-related task (for example insulin administration), this must be supported by written delegation instructions, role-appropriate training, competency assessment and ongoing review in line with the All Wales Guidelines for Delegation.
• Step 6: Document all medication assistance in the eMAR system immediately, including dosage, time, and method of administration.

For CIW Inspectors:

• eMAR records confirm that medication administration is documented and tracked according to CIW regulations.
• Training logs ensure that staff are competent and regularly assessed on their medication administration skills.

B. Medication Storage and Security

In domiciliary care, medicines remain the property and responsibility of the individual (or their representative) unless specific arrangements are agreed in the personal plan. We support people to store medicines safely in their own home in a way that balances safety and independence.

• Complete and record a medicines storage risk assessment (including risks from children/visitors, cognition, pets, heat/light/moisture, fridge medicines and sharps).
• Agree a safe storage location with the individual (and representative where appropriate) that is clean, dry, secure and appropriate to the medicine’s storage requirements.
• Where additional security is needed, agree use of a lockable container/cabinet within the home, and record who holds access/keys. Staff must not remove medicines or keys from the home unless explicitly authorised and documented.
• Controlled drugs: where controlled drugs are used, confirm the storage arrangement recorded in the personal plan and follow the controlled drugs procedure for recording, counting where appropriate, and escalation of discrepancies.
• Check expiry dates when supporting administration and prompt return of discontinued/expired medicines to the community pharmacy for safe disposal.

For CIW Inspectors:

• Medication storage audits confirm that medications are kept securely and are compliant with regulatory standards.
• Inventory records demonstrate that stock levels and expiry dates are accurately recorded and managed.

C. Maintaining Supply, Ordering/Re-ordering and Reconciliation

For Staff:

• At each visit (or as specified in the plan), check whether the individual has sufficient medicines until the next planned re-order date, paying particular attention to time-critical medicines and PRN stock.
• Where the service is responsible for prompting or supporting re-ordering, follow the agreed process recorded in the personal plan (for example: inform the family/representative; contact the nominated pharmacy; follow GP repeat ordering arrangements).
• On receipt of medicines (including monitored dosage systems), reconcile the medicines delivered against the MAR, dispensing label and current directions. Any discrepancy (missing item, wrong strength, unclear directions, change not reflected on MAR) must be escalated to the pharmacy/GP and recorded before administration occurs.
• Record all actions taken (who was contacted, outcome, and any interim risk controls).

For CIW Inspectors:

• Records demonstrate robust arrangements for maintaining supply, re-ordering, reconciliation and escalation of discrepancies.

D. Supporting Service Users in Self-Administration

Where appropriate, service users may be encouraged and supported to self-administer their medications to maintain their independence.

For Staff:

• Complete a Self-Administration Assessment (SAA) to determine whether the service user is capable of taking their medication independently.
• Provide regular reminders and prompts for service users who can manage their medication independently.
• Ensure that medication is safely stored, and reminders are provided for timely administration (e.g., through blister packs or medication organisers).

For CIW Inspectors:

• Self-administration assessments are documented and show that the service user has the ability and understanding to manage their medications.
• Care plans reflect that the service user is empowered to self-administer if it aligns with their preferences and capacity.

E. Managing Medication Errors and Missed Doses

In the event of a medication error or missed dose, we take immediate steps to correct the issue and prevent recurrence.

For Staff:

• Report any medication errors or missed doses immediately through the Incident Reporting System (IRS).
• Follow the Medication Incident Procedure (MIP), including checking the service user’s medication records for discrepancies and ensuring that the missed dose is administered correctly (with consultation with a healthcare professional if needed).
• Document the incident and outline corrective actions taken, ensuring the service user’s safety is not compromised.

For CIW Inspectors:

• Incident records demonstrate that medication errors are reported and investigated promptly.
• Corrective action logs confirm that measures are implemented to prevent similar errors in the future.

F. Covert Administration of Medicines

Covert administration (disguising medicine in food/drink without the person’s knowledge) is a restrictive practice and will only be used where it is lawful, necessary and proportionate.

For Staff:

• Covert administration must never be used routinely or for convenience.
• Before any covert administration, the Registered Manager must ensure:
  • a mental capacity assessment has been completed in relation to taking the medicine;
  • a best-interests decision has been made and documented (including less restrictive options tried);
  • advice is obtained from the prescriber/pharmacist about whether the medicine can be safely given covertly; and
  • a clear covert administration plan is included in the person’s medicines plan (what medicine, how, when, review date).
• The arrangement must be reviewed regularly and immediately if the person’s presentation changes or concerns are raised.

For CIW Inspectors:

• Records evidence lawful authority, best-interests decision making, professional involvement and review.

G. ‘When required’ (PRN), Variable Dose and Time-Critical Medicines

For Staff:

• PRN medicines must only be given where there is a written PRN protocol (symptoms/indications, minimum interval, maximum daily dose, and when to seek clinical advice).
• For variable dose medicines (e.g., warfarin/insulin sliding scales), staff must follow the most current written directions and record the source of the direction (e.g., dose instruction sheet, prescriber instruction). If unclear, do not administer—escalate immediately.
• Time-critical medicines must be prioritised to avoid missed/late doses; where a dose is likely to be missed, follow the missed-dose process and seek advice where required.

H. Staff Training and Competency in Medication Assistance

Ensuring that all staff are competent and confident in assisting with medication is crucial to maintaining high standards of care.

For Staff:

• Complete Medication Administration Competency (MAC) training as part of induction and annual refresher courses.
• Participate in medication management workshops that include practical training on the safe administration of various types of medication.
• Undergo supervision and competency assessments to ensure continued compliance with best practices.

For CIW Inspectors:

• Training logs confirm that all staff involved in medication assistance are appropriately trained and assessed.
• Competency reviews demonstrate that staff have up-to-date knowledge and skills to assist with medication safely.

I. Medication Reviews and Monitoring

We work closely with healthcare professionals to ensure that service users’ medications are reviewed regularly and that any changes in their condition or treatment needs are appropriately managed.

For Staff:

• Collaborate with GPs, pharmacists, and other healthcare providers to ensure that service users’ medications are appropriate, effective, and safe.
• Monitor service users for side effects or adverse reactions to medications and report these promptly to the Registered Manager or healthcare professional.
• Regularly review care plans to ensure that medications remain appropriate to the service user’s evolving health needs.

For CIW Inspectors:

• Medication review documentation shows that service users’ medication is regularly evaluated for safety, efficacy, and appropriate adjustments.
• Collaboration logs with healthcare professionals demonstrate that medications are monitored and adjusted in accordance with the service user’s changing needs.

4. Governance and Continuous Improvement

We ensure high standards of medication management through continuous audits, training, and quality improvement.

What We Do:

• Conduct Quarterly Medication Audits (QMA) to monitor compliance with medication policies and procedures.
• Hold Annual Medication Safety Reviews (AMSR) to assess medication handling practices and identify areas for improvement.
• Incorporate service user feedback and incident reports to continuously improve medication processes.

For CIW Inspectors:

• Audit records confirm regular assessments of medication management processes.
• Action plans demonstrate improvements based on audit findings and feedback from service users.

5. Compliance Monitoring and Audit Procedures

• Internal Audits: Conducted quarterly to ensure compliance with medication management policies.
• Annual Reviews: Full compliance check against the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 (as amended) including Regulation 58 (Medicines), Welsh Ministers’ statutory guidance (2024), and current best practice guidance including NICE NG67.
• Staff Supervisions & Appraisals: Carried out every six months to assess staff competence in medication assistance.

6. Conclusion

We are committed to ensuring that medication assistance is provided in a safe, effective, and compliant manner in full accordance with CIW regulations, best practice guidelines, and the Medicines Act 1968. This policy ensures that service users receive the correct medication, delivered safely and in a person-centred manner, while staff are fully trained and supported in their roles.

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