CHW21-Medication Management and Administration Policy

Registration Number: {{org_field_registration_no}}

Medication Management and Administration Policy

1. Purpose

The purpose of this policy is to ensure the safe, legal, and effective management of medication within {{org_field_name}}, safeguarding the health, well-being, and dignity of all service users. This policy aligns with the Regulation and Inspection of Social Care (Wales) Act 2016, The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, and best practices set by Care Inspectorate Wales (CIW).

Effective medication management helps to:

Prevent medication errors and adverse drug reactions.
Promote safe handling, storage, and disposal of medication.
Ensure staff competency in medication administration.
Support service users in managing their own medication, where appropriate.

2. Scope

This policy applies to:

All staff members involved in medication handling, administration, and recording.
Registered Manager and Responsible Individual, ensuring compliance with CIW regulations.
Service users and their families, ensuring informed consent and self-administration choices.
External healthcare professionals, such as pharmacists and general practitioners.

3. Related Policies

This policy should be read in conjunction with:

Safe Care and Treatment Policy (CHW11)
Health and Safety at Work Policy (CHW16)
Infection Prevention and Control Policy (CHW17)
Risk Management and Assessment Policy (CHW18)
Safeguarding Adults from Abuse and Improper Treatment Policy (CHW13)
Confidentiality and Data Protection Policy (CHW34)
Duty of Candour Policy (CHW35).

4. Policy Statement

{{org_field_name}} is committed to ensuring safe medication practices through strict adherence to legal frameworks, robust staff training, and continuous monitoring. Medication is handled with respect for service users’ rights, preferences, and medical needs, ensuring safety, dignity, and choice.

5. Implementation and Management

5.1 Governance and Leadership

The Responsible Individual (RI) ensures overall compliance with CIW regulations.
The Registered Manager oversees medication procedures, audits, and staff training.
A Medication Lead is appointed to manage medication stock, documentation, and staff queries.

5.2 Medication Ordering and Receipt

Medications are ordered only by authorised personnel via a pharmacy-approved prescription system.
Service users and families are consulted about their medication preferences.
Upon receipt, all medications are checked for accuracy against prescriptions before being signed into stock.

5.3 Storage of Medication

Medications are stored in a locked, temperature-controlled area, accessible only to authorised staff.
Controlled drugs (CDs) are stored in a CD-compliant safe with restricted access.
Medication requiring refrigeration is stored in a designated medication fridge, with daily temperature checks.
Expired or discontinued medications are returned to the pharmacy for disposal following legal protocols.

5.4 Medication Administration Procedures

Medications are administered only by trained and competent staff.
Staff follow the six rights of medication administration:
1. Right Person – Confirming identity via photo ID and care plan.
2. Right Medication – Checking prescription and label.
3. Right Dose – Verifying dosage and administration instructions.
4. Right Route – Ensuring medication is given correctly (e.g., oral, topical).
5. Right Time – Administering as scheduled, avoiding missed doses.
6. Right Documentation – Recording immediately after administration.
Service users are encouraged to self-administer medication, where appropriate, following a risk assessment.
PRN (as-needed) medications are only administered with a clear rationale and documented effect.

5.5 Administration of Controlled Drugs (CDs)

CDs are administered by two trained staff members, one acting as a witness.
Administration is recorded in a CD register, signed by both staff members.
Regular audits ensure CDs are stored and recorded in accordance with the Misuse of Drugs Act 1971.

5.6 Covert Medication Administration

Covert administration is only used as a last resort for individuals lacking capacity, following a best interest meeting with medical professionals and family.
A Covert Medication Plan is documented and reviewed regularly.

5.7 Medication Errors and Incident Reporting

All medication errors and near misses are reported immediately to the Registered Manager.
A Root Cause Analysis (RCA) is conducted for serious incidents, and findings are used to prevent recurrence.
Errors are recorded using the CIW incident reporting process if necessary.

5.8 Staff Training and Competency

All staff involved in medication handling undergo training on safe administration, recognising side effects, and documentation.
Annual competency assessments ensure continued staff proficiency.
Staff receive additional training on administering specialist medications, such as insulin or PEG feeds.

5.9 Medication Audits and Compliance Monitoring

Weekly medication audits identify discrepancies, stock levels, and expiry dates.
Quarterly external pharmacy reviews ensure compliance with best practices.
Feedback from service users and families informs improvements in medication management.

5.10 Disposal of Unused or Expired Medications

All unused or expired medication is returned to the pharmacy for safe disposal.
A medication disposal log is maintained and audited regularly.

5.11 Supporting Service Users with Self-Administration

Service users are supported in managing their own medication, where safe to do so.
A risk assessment is conducted to determine the level of support required.
Medication storage and self-administration competency are reviewed regularly.

6. Compliance with Legislation and Regulations

This policy ensures compliance with:

The Regulation and Inspection of Social Care (Wales) Act 2016.
The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017.
The Medicines Act 1968.
The Misuse of Drugs Act 1971 (for controlled drugs).
The Health and Safety at Work Act 1974.
The Social Services and Well-being (Wales) Act 2014.
CIW standards on medication safety and reporting.

7. Policy Review

This policy will be reviewed annually or sooner if legislative requirements change. The Registered Manager is responsible for ensuring this policy remains current and effective.

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.