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CH209-Medication Procedures During Resident Outings and Leave Policy

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Medication Procedures During Resident Outings and Leave Policy

1. Purpose

The purpose of this policy is to ensure the safe, legal, and effective handling of medicines during outings, appointments, short breaks, or leave periods involving individuals receiving care from {{org_field_name}}. It supports staff in managing medication appropriately while outside the usual care setting, protecting the health and wellbeing of individuals, and complying with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 12 (Safe care and treatment – proper and safe management of medicines) and Regulation 17 (Good governance – effective systems to assess, monitor and improve quality and safety). It also reflects CQC medicines management expectations for adult social care, including safe ordering, transport, storage, administration, recording, and disposal of medicines, safe transfer of medicines information between settings, and learning from medication incidents and near misses.

2. Scope

This policy applies to all care and support staff involved in administering, managing, or supporting medication during any outing or period of leave for an individual receiving care in the community. It covers prescription medicines, PRN (as required) medication, over-the-counter medications, and controlled drugs (CDs) where applicable.

3. Related Policies

4. Policy Statement

{{org_field_name}} is committed to ensuring that individuals receive their medication correctly and safely regardless of location. This includes ensuring that medication is transported securely, administered at the correct time, and recorded accurately during any time spent away from the individual’s home. We promote autonomy and involvement while ensuring robust procedures are followed to minimise risk and comply with legal and professional standards.

5. Key Procedures and Guidance

Pre-Outing Medication Planning

Before an outing, care staff must review the individual’s medication administration record (MAR), care plan, and risk assessment to determine if any medication is due during the time away. If so, an outing-specific medication plan is completed, outlining what medication is required, timing, dosage, and any storage instructions. A named staff member is assigned responsibility for medication management during the outing.

Consent and Capacity

The individual must be fully involved in the planning and consent to the outing and the associated medication arrangements. If the individual lacks capacity, decisions are made in their best interests following the Mental Capacity Act 2005, and in consultation with their representative or advocate. Consent must be documented clearly in the care plan. Covert administration must never be used for convenience during outings; it may only be considered following a documented capacity assessment and best-interests decision, with a clear care plan and agreed method of administration, in line with the organisation’s covert medicines process.

Medication Preparation and Transportation

Only the medication required for the outing is prepared and taken, using a secure and clearly labelled container or pouch. Medication is dispensed from the original packaging where safe and legal to do so. Labels must include the person’s name, medication name, dose, timing, and route of administration. Staff must never decant medication into unlabelled containers or carry multiple individuals’ medication together. Where controlled drugs (CDs) are required during an outing, staff must follow the organisation’s Controlled Drugs procedure and current best practice guidance for adult social care. CDs must be kept secure at all times, access restricted, and any administration must be recorded clearly (including dose, time, and where required a running balance). Any discrepancy, loss, damage, or suspected diversion must be treated as an immediate safeguarding concern and medicines incident and escalated without delay in line with reporting requirements.

Staff must not remove tablets/capsules from pharmacy-labelled packaging (including multi-compartment compliance aids/blister packs) until the point of administration, unless a pharmacist has supplied an appropriately labelled container for the outing period. If a separate labelled container is provided, it must clearly show: the person’s name, medicine name and strength, dose, route, timing/frequency, and any cautionary advice. Unlabelled pots, envelopes, or loose tablets/capsules are not permitted.

Storage During Outing

All medication must be stored securely throughout the outing, away from extreme temperatures and out of reach of unauthorised individuals. Staff must not leave medication unattended. If medication must be refrigerated or stored under specific conditions, this must be considered during planning, and outings adapted accordingly.

Cold-chain / temperature-sensitive medicines

Where a medicine requires refrigerated storage or has specific temperature limits, staff must plan the outing to maintain safe storage and use an appropriate insulated container/cool pack where required. The medicine must be kept within the required range for the shortest possible time. Any significant temperature deviation, damage, or uncertainty about suitability must be treated as a medicines incident. The medicine must not be administered until advice is obtained (for example from the supplying pharmacy, GP, or prescriber as appropriate), and all actions and advice must be documented.

Administration of Medication While Away

Only staff trained and authorised to administer medication may do so during outings. The standard 5 Rights of Medication Administration must be followed: right person, right medication, right dose, right route, right time. Administration must be documented immediately using a portable MAR or medication record sheet, with details transferred to the main MAR on return.

Documentation pack and transfer of medicines information

Before leaving the usual care setting, staff must prepare an Outing Medicines Pack (paper or electronic) that includes, as a minimum:

Any changes made by external healthcare professionals during the outing (new medicines, stopped medicines, dose changes) must be verified (for example by discharge documentation, clinic letter, or updated pharmacy label) and then updated on the care plan and MAR promptly on return, in line with the organisation’s medicines governance process.

PRN and Emergency Medication

Where PRN medication (e.g. pain relief, inhalers, emergency epilepsy medication) may be needed, staff must carry it and have clear guidance on when and how to administer it. This includes access to protocols, signs and symptoms to look for, and steps to take if the medication is ineffective or not tolerated. Any administration of PRN medicine must be recorded and reported upon return.

Missed or Refused Doses

If medication is missed, delayed, or refused during the outing, staff must document the reason and notify the Registered Manager or on-call lead immediately. A risk assessment is conducted to determine the need for medical advice or action. The missed dose must also be recorded on the individual’s MAR with a clear explanation.

Disposal/returns after outings (including waste and sharps)

Any medicines taken on an outing that are unused must be returned to the person’s medicines storage area immediately on return and reconciled against the outing record. Medicines must not be disposed of in household waste. Where disposal is required (for example discontinued medicines or part-used liquids), staff must follow the organisation’s disposal process and document: date, medicine name and strength, quantity, reason for disposal/return, and where it was taken (named pharmacy or approved waste contractor). Controlled drugs and sharps must be managed and disposed of in line with the organisation’s controlled drugs and sharps procedures.

Outings Involving Family or External Parties

If medication responsibility is transferred to a family member or external support provider during a leave period, this must be agreed in writing. Details must include who will administer medication, what medication has been handed over, and what records will be maintained. Copies of MARs, medication lists, and administration guidance may be provided as appropriate. Staff must not release medication without a clear handover process.

Incident Reporting

Any medication error, incident, or near miss that occurs during an outing must be reported immediately using the organisation’s incident reporting system. A root cause analysis is carried out by the management team, and lessons learned are shared to improve future practice.

Where a medicines incident results in, or could result in, harm, the service must consider and follow the organisation’s Duty of Candour process, including open communication with the person (and/or representative), an appropriate apology, and written follow-up where required. Relevant professionals (for example the GP, prescriber, or supplying pharmacy) and safeguarding leads must be notified where indicated. Actions, learning, and outcomes must be tracked to completion through governance.

Staff Training and Competence

All staff involved in administering or managing medication during outings must be trained and deemed competent in medication handling, emergency protocols, safeguarding, and the specific needs of the individual they are supporting. Refresher training is provided annually or sooner if required due to role changes or identified learning needs.

Delegated medicines administration

If any medicines administration task is a delegated healthcare activity (for example injections, administration via a PEG/feeding tube, complex wound-related medicines, or other clinical tasks), it must only be undertaken where a Registered Nurse (or other appropriate registered professional) has formally delegated the task, confirmed competence, and provided clear written instructions, escalation guidance, and review arrangements. Delegation must be in the person’s best interests, consent and capacity must be considered, and staff must follow the organisation’s delegated healthcare activities procedure.

6. Responsibilities

The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} is responsible for ensuring the implementation of this policy and that all outings involving medication are risk assessed, documented, and monitored. Staff are responsible for following procedures, reporting concerns, and supporting individuals safely and respectfully.

The Registered Manager is also responsible for ensuring this policy is implemented through effective governance systems, including: routine audit of outing medication records and MAR entries; review of medicines incidents and near misses for themes and trends; implementation and monitoring of action plans with timescales and accountable owners; and assurance that staff training, competency assessments, and refresher training remain current and effective.

7. Policy Review

This policy will be reviewed annually, or earlier if legislation, CQC guidance, or organisational processes change. All staff will be informed of updates and provided with additional training where necessary.

Appendix A – Outing Medication Plan and Record
Person: ___________________________
Date: _____________________________
Destination(s): ____________________
Staff responsible: _________________

Medicines due during outing (name/strength/dose/route/time):

PRN medicines carried and protocol attached (Y/N): _________
Storage requirements (e.g., cold-chain): __________________

Handover to family/third party? (Y/N): ________
If yes, record name/role, time, medicines handed over, and signatures:

Administration record (time / medicine / dose / outcome / staff signature):

Variance record (refused/missed/delayed + reason + actions taken):

Reconciliation on return (medicines returned / remaining balance checked / signature):

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.

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