CH45-Assisting Service Users with Medication Policy

Registration Number: {{org_field_registration_no}}

Assisting Service Users with Medication Policy

Purpose and Scope

This policy sets out how {{org_field_name}} supports service users with their medications safely and in compliance with the Care Quality Commission (CQC) standards. It covers all aspects of medication support – from simply assisting or prompting service users, to full administration by trained staff – depending on each individual’s needs. The policy applies to all staff and service users in our CQC-registered care homes in England. It addresses support for service users who self-administer their medicines (with capacity) as well as those who lack capacity and require assistance or direct administration. All forms of medication are included within the scope – prescribed medications (those ordered by a healthcare professional) and non-prescribed medications (over-the-counter remedies, herbal supplements, “homely remedies”, etc.), to ensure they are used as intended and recorded properly. By following this policy, the home aims to promote the health, safety, independence and dignity of service users in all matters relating to their medicines, in line with relevant legislation and best-practice guidance (e.g. Health and Social Care Act 2008 Regulated Activities Regulations, Regulation 12 on safe care and treatment, and NICE guidelines on managing medicines in care homes).

Policy Statement and Principles

We are committed to safe, effective, and person-centred medication management. Our core principles in assisting with medication include:

Safety: Medications must be managed safely at all times. They will be obtained, stored, administered and disposed of in a manner that prevents harm and errors. Staff administering or assisting with medication will strictly adhere to the “six rights” of medication administration: the right person, right medication, right dose, right time, right route, and the service user’s right to refuse medication.
Consent and Dignity: Service users will be involved in decisions about their medicines to the fullest extent possible. Their consent will be sought for medication support, and their preferences, beliefs and privacy will be respected. Service users have the right to refuse medication, and such refusal will be handled without coercion – documented and reported in line with care plans and medical advice.
Independence: We aim to enable and encourage service users to manage their own medication if they wish and are able to do so safely. Staff will assume a person can self-administer their medicines unless a risk assessment indicates otherwise. Maintaining independence in medication is important for dignity and autonomy; therefore, assistance will be tailored to each individual’s abilities.
Accountability and Compliance: All staff must follow this policy and related procedures. We comply with CQC Fundamental Standards and relevant guidance (such as NICE Guideline SC1) to ensure medicines are handled properly and service users receive their prescribed and non-prescribed treatments as intended. Only trained and competent staff are permitted to assist with or administer medications, and they are accountable for their actions in doing so. Clear records will be kept for every medication-related task, ensuring transparency and continuity of care.
Holistic Care: Medication support will be delivered in a person-centred way, considering each service user’s overall well-being. We coordinate with healthcare professionals (GPs, pharmacists, community nurses) for medication reviews, changes to prescriptions, and to address any issues such as side effects or effectiveness of medications. Non-medication alternatives (such as lifestyle measures or non-pharmacological interventions) will also be considered where appropriate to avoid over-reliance on medicines. Importantly, medication will never be used inappropriately as a form of restraint or control of behavior (chemical restraint), in line with CQC expectations. Any use of sedative or psychotropic medication will be carefully justified, monitored, and reviewed.

Roles and Responsibilities

Registered Manager: The Care Home Manager holds overall responsibility for the implementation of this medication policy. The manager must ensure that there are up-to-date procedures in place for all aspects of medicines management and that staff are trained and competent. The manager (or a designated senior staff member) will: perform or oversee initial assessments of service users’ medication support needs; regularly review medication management (including audits of Medication Administration Records and practices); investigate any medication errors or incidents; liaise with doctors and pharmacists as needed; and ensure compliance with legal and regulatory requirements for medicines . The manager also coordinates risk assessments for self-administration and decides, in collaboration with the multidisciplinary team, how each individual’s medicines should be managed.

Care Staff (Care Assistants and Nurses): All care staff who assist with or administer medications are responsible for following this policy in their daily work. They must only undertake medication tasks for which they have been trained, authorised, and assessed as competent. Key responsibilities of care staff include: checking and giving medicines according to the prescription and the “six rights” protocol; documenting every medication given, refused, or assisted on the MAR chart; observing and reporting any side effects or issues; maintaining the security of medicines (e.g. keeping medication trolleys/cabinets locked); and respecting the privacy and dignity of service users during medication rounds. Care staff also have a duty to report promptly to the Manager (or senior on duty) if they encounter any medication errors, discrepancies, or if a service user has issues with their medicines (such as frequent refusals or difficulty swallowing pills).

Senior Care Staff / Team Leaders: Senior staff may be assigned to oversee medication management on each shift. They ensure that medication rounds are completed correctly, double-check controlled drug administration, handle ordering and receiving of medication from the pharmacy, and provide guidance to junior staff. Senior staff should verify that new prescriptions are accurately transcribed onto MAR charts (if needed) and that discontinued medications are removed from use. They also play a role in mentoring and assessing the competency of care staff in medication tasks, and they may carry out witness signatures for controlled drugs or insulin administration according to policy.

Service Users (Residents): Service users are encouraged to be active partners in managing their own health and medicines. Those who self-administer or wish to self-administer should cooperate with the home’s risk assessment and agree on any necessary safety measures (for example, using secure storage in their room). Service users (or their representatives) should inform staff of any medications they are taking independently, including over-the-counter or herbal products, so that the home can record these and help monitor for any potential interactions or adverse effects. Service users are asked to communicate openly about any difficulties they have with taking medicines (e.g. trouble swallowing, undesirable side effects) so that staff can arrange support or medical review. If a service user lacks capacity, their advocate or representative (such as a family member or person with Lasting Power of Attorney for health) will be involved in decisions about medicines on their behalf.

Assessing Medication Support Needs

Upon admission and regularly thereafter, an individual medication needs assessment is conducted for each service user. This assessment determines the level of support required with medications and is documented in the person’s care plan . Key areas of assessment include the person’s cognitive capacity, understanding of their medicines, physical ability to self-administer (e.g. can they open bottles or handle inhalers), and their preferences regarding independence with medication. Staff will assume capacity and ability to self-medicate by default, in line with NICE guidance, and will only recommend staff administration if a risk assessment shows that self-administration would be unsafe.

As part of the assessment, we consider:

The service user’s choice and consent: Does the individual want to manage their own medication, and do they consent to staff assistance if needed? Each person’s wishes are central to the plan.
Risks to the person or others: Would self-administration or a lower level of support pose any danger? For example, we evaluate if there’s a risk of overdose, missed doses, confusion, or medicines being accessed by others (especially in a shared environment).
The person’s abilities (Capacity and Dexterity): We assess whether the service user can take the correct medication at the right dose and time reliably. This includes considering mental capacity (do they remember to take it and understand why?) and physical ability (can they manipulate packaging, measure liquids, use inhalers, etc.). Abilities may vary for different medications – for instance, a person might handle oral tablets independently but need help with eye drop administration. If there are concerns about memory or understanding, a formal mental capacity assessment may be done for the specific decision of managing medication.
Storage arrangements: If the person is to self-administer, how and where will their medicines be stored securely? We ensure that any self-held medication can be kept in a lockable place (e.g. a locked drawer or cabinet in the resident’s room) that is not accessible to others, while still being accessible to the resident when needed. Staff will determine if the resident will hold the key or if staff will assist with access, depending on the risk assessment.
Frequency of review: We decide how often the person’s ability to manage their medicines will be reassessed. For example, if someone’s health or cognition is changing, we may review monthly; otherwise, perhaps at each care plan review or sooner if a concern arises. Any acute illnesses or changes in condition will prompt an immediate re-evaluation of their medication support needs.
Staff responsibilities and monitoring: The care plan will clearly document what tasks staff are responsible for, even when a person self-medicates. For example, staff might be responsible for ordering repeat prescriptions and monitoring adherence (checking that the person is taking doses as prescribed). A method for monitoring might include counting pills periodically or having the resident record doses on a chart, depending on what is agreed as “an effective way of monitoring adherence”.

Each individual’s medication support plan is recorded in their care plan and communicated to all relevant staff. The Registered Manager coordinates the initial assessment and involves appropriate people: the service user themselves, family or representatives (if the person agrees), care staff with knowledge of the individual, and healthcare professionals as needed. For example, we may involve the person’s GP or a pharmacist for advice on simplifying a regimen (such as using easy-open containers or blister packs) to facilitate self-administration.

This assessment approach ensures that service users with capacity are supported to self-administer if they wish, unless it’s unsafe, and that those who lack capacity or who prefer not to self-administer receive the appropriate level of staff support. We document the outcome: whether the person will self-administer, require prompts, or have staff administer their medications. A copy of the risk assessment and agreed plan is kept in the care record.

Consent and Mental Capacity

We recognise the fundamental requirement to obtain consent for any care or treatment, including assistance with medication. Service users with capacity have the right to make informed decisions about taking medications. Staff will explain what each medicine is for and answer any questions, enabling the individual to consent to or decline medication at the point of administration. A service user’s consent to have staff administer their medication (or to be assisted with it) is usually obtained as part of the care planning process and documented in their records. It is not required to reconfirm formal written consent every time a dose is given; however, staff will use a person-centred approach, confirming each time that the person is willing to take their medicines (and respecting their wishes if they decline).

If a service user refuses a medication, staff will follow the procedure: encourage but do not force, ask if there’s a reason (like side effects or misunderstanding), and respect the refusal. The refusal is recorded on the MAR chart and in the daily notes, including any stated reason. If the medication is critical to health or if refusals persist, staff will inform the prescribing healthcare professional (e.g. GP) for advice. We may also need to inform the supplying pharmacy to pause further supply if the medicine is consistently not being taken.

For service users who lack mental capacity to make informed decisions about their medication, we follow the Mental Capacity Act 2005 and its Code of Practice. A mental capacity assessment will be conducted for the specific decision of managing and taking medication. If the person is deemed not to have capacity for this, any decision to administer medication on their behalf (including the level of assistance or the use of covert administration) will be made under a best interests decision. The best interests process will involve relevant parties such as the person’s family or legal representative, healthcare professionals (GP, pharmacist), and care staff who know the person, considering the person’s past and present wishes, feelings, values, and needs. All best-interest decisions regarding medication will be documented clearly in the care plan.

If a service user without capacity is resistant to taking essential medication, the team may consider covert administration (hiding medicine in food/drink) only as a last resort and with strict safeguards. Covert medication will never be given just for convenience or without proper authorisation. We will ensure there is a formal best-interest meeting and plan in place, which includes the prescriber’s authorisation and, ideally, pharmacy guidance on safe mixing (to maintain the medicine’s effectiveness). A covert medication plan will detail which medicines can be given covertly and how, and it will be reviewed frequently for continued necessity. Our procedures for covert administration are in line with the Mental Capacity Act and professional guidance – meaning we document the rationale and obtain appropriate approvals. Covert administration steps (and reviews of its need) will be recorded in the care plan and kept under regular review. If the person’s capacity improves or alternative approaches become viable, covert administration will cease.

Self-Administration of Medication

{{org_field_name}} supports and enables service users to self-administer their medicines wherever safely possible. Self-administration means the person retains responsibility for taking their own medication (in contrast to staff administering it). As noted, staff will initially presume a resident can self-medicate unless an assessment shows this to be unsafe. For each service user who self-administers, we implement the following safeguards and arrangements (per our policy and NICE guidelines):

Individual Risk Assessment: Before self-administration begins, a thorough risk assessment is completed (as described above under assessing needs). This ensures that self-medication will not pose undue risk and identifies what support, if any, is needed. The assessment is documented and the decision to permit self-administration is agreed by the care team and resident.
Obtaining and Ordering Medicines: Staff will typically continue to handle ordering and collecting the service user’s medicines from the pharmacy, even if the person takes them independently. This ensures a continued supply and that medicines come with appropriate pharmacy labels and instructions. However, some individuals may prefer to order their own repeats – this can be arranged if appropriate, with oversight. In all cases, the home’s ordering process will account for the person’s prescriptions so that no doses are missed.
Secure Storage: Medications for self-administering residents will be stored in a manner that balances security with the resident’s independence. Usually, a lockable drawer or cabinet is provided in the resident’s room for their medications. The storage must be such that other people (roommates, visitors, other residents) cannot access the drugs, especially important for controlled drugs or medicines that could harm if taken by someone else. Depending on the risk assessment, the resident may hold the key to their medication drawer, or staff may hold it and provide access at agreed times – this will be decided case by case. The care plan will specify how medicines are stored and who has access. We also ensure the resident can access their medicine when needed (for example, pain relief PRN should not be locked away beyond their reach). If any medicine requires refrigeration, a secure arrangement (such as a locked box in a shared fridge, or a dedicated medication fridge) will be used.
Record-Keeping: Even with self-administration, some records are maintained by staff. We note on the MAR chart and care plan which medications a person self-administers. According to CQC guidance, individual doses taken by the person do not need to be recorded on the MAR each time, to respect their independence. Instead, the MAR can indicate “self-administering” for that medicine. However, whenever staff are involved in any way – for example, reminding the person to take a dose or handing them a container – this counts as providing medicines support and must be recorded (either on the MAR or daily notes). Essentially, if staff assist or prompt, we treat it as a medication event to document. We also ask the resident to inform us (or we will discreetly check) if they have taken or missed doses, as part of monitoring adherence. If a self-medicating resident forgets doses or has difficulty, the level of support will be increased accordingly (after re-assessment).
Supporting and Monitoring: Self-administering residents will be given any reasonable adjustments or aids to help them manage. For example, we can provide reminder charts or alarm reminders, easy-open pill containers, large-print labels for those with visual impairment, color-coded labels, pill organizers (dosette boxes) if assessed as suitable, or devices to assist with inhalers and eye drops . Staff might also arrange information sessions or written information about the medicines in an accessible format for the resident. We will periodically check on the person’s adherence according to the care plan – this could involve weekly check-ins, asking if they are managing, or doing pill counts if appropriate (with consent). If any issues are noted (e.g. doses consistently missed or signs of overdose), staff will intervene and possibly revise the care plan. Monitoring is done sensitively to respect that the person is in charge of their own medication, while still ensuring safety.
Disposal of Unused Medicines: Even for self-medicating individuals, the care home will assist in disposing of any discontinued or expired medication. The resident should not throw medications away themselves or keep large quantities of old drugs. Staff will periodically ask if there are any medications that need disposal and will handle returning them to the pharmacy or disposing as per regulations. If the person self-administers a PRN (as-needed) medication that they ended up not using, for instance, we ensure it is safely stored until expiry or returned when no longer needed.

Our process for self-administration is documented and includes all the above elements, as recommended by CQC/NICE (individual risk assessment, obtaining medicines, storage, record-keeping, support, monitoring, and disposal). We review each self-medication arrangement regularly. If a resident’s ability to self-administer declines (e.g. due to worsening memory or health), we will adjust the support level — possibly transitioning to staff administration — in consultation with the resident and relevant professionals. Conversely, if a resident wishes to take on more responsibility and it appears safe, we will support a move from full staff administration to partial or full self-administration after a positive risk assessment.

Assisting with Medication (Prompting and Physical Assistance)

Some service users may not manage all aspects of their medicines alone but do not require full administration by staff. In these cases, our staff will assist or prompt the individual, providing just the level of help needed. Medication assistance can include a range of activities, for example:

Prompting/Reminding: Verbally reminding the service user that it is time to take their medication, or asking if they have taken it. This might involve bringing the medicines to the person’s attention at the correct time, especially if they tend to forget. Staff will always do this in a respectful manner, preserving the person’s sense of autonomy (e.g. “It’s 8am, here’s your medicine, would you like to take it now?”).
Practical Assistance: Helping the person with tasks like opening medication packaging or containers, preparing a dose (for instance, shaking a liquid medicine bottle, or popping tablets out of a blister pack and handing them to the person), or reading labels/instructions if the individual cannot read them. The key distinction is that the service user then takes the medication themselves once the staff has assisted with these preparatory steps.
Observing and Encouraging: Staff might stay with the person to ensure the medicine is taken properly (especially if there’s a risk the person might forget to actually swallow the pills after they are prompted). They can provide encouragement or clarification – for example, reminding the person to drink water with their tablets. However, the service user remains in control of taking the medication into their body.

All assistance of this nature is outlined in the care plan so that staff know exactly what kind of help each person needs (and the person has agreed to). For example, a care plan might state: “NameName can administer her inhalers independently once they are prepared; staff to shake the inhaler and attach the spacer for her due to her arthritis, then she will self-inhale.” By clearly defining the assistance, we maintain consistency and safety.

Importantly, even when staff are only prompting or assisting, they must treat it with the same care as full administration: check the correct medication and dose is being prompted at the correct time, confirm the person’s identity, and document the assistance given. According to CQC guidance, prompting or helping a person remove medicines from packaging is considered part of “medicines support” and should be documented and care-planned. In practice, this means if a staff member prompts a medication, they will make an entry on the MAR (or other record) indicating that the dose was taken with prompting. If the person ultimately refuses or does not take it, that is noted as well. This ensures our records reflect all medication-related support, not just instances of direct administration.

If at any point assisting or prompting is not sufficient to ensure the person is safely taking their medication, staff will escalate to the manager for a care plan review. The plan might then change to full administration by staff if needed. Conversely, if a person becomes more confident, we can reduce the level of assistance (with management approval).

Administration of Medication by Staff

When a service user is not self-medicating (either by choice or due to assessed need), trained care staff will administer the medication directly. This means the staff takes responsibility for measuring out or preparing the medicine and giving it to the service user to ingest, apply, or inhale, etc. Staff administration of medication will be carried out in a safe, competent, and person-centred manner as described below:

1. Preparation and Verification: Before administering any medicine, the staff member will prepare by checking the MAR chart and the pharmacy dispensing label/prescription for the following details: the service user’s name, the medication name and form, the dose (strength and quantity), the route (e.g. by mouth, external application), and the time it is due. They will also verify if there are any special instructions (such as “with food” or blood pressure check before giving, etc.). The staff must ensure they have the correct service user and will typically do this by positively identifying the person (for example, by calling the person’s name and confirming identity, or per our identification protocols). They will then proceed according to the “six rights” of medication administration to prevent errors: right person, right medicine, right dose, right time, right route, and confirming the person’s right to refuse.

2. Infection Control and Equipment: Staff will wash or sanitize their hands prior to handling medications and use any necessary protective equipment (such as gloves if touching tablets or applying creams) to ensure hygiene. Clean medicine cups, syringes or spoons for liquid medicine, or tubing for PEG feeds, etc., will be used as needed for accurate administration. If using a monitored dosage system (e.g. blister pack), staff will ensure they have the correct compartment for the correct time and date.

3. Explaining and Consent: When approaching the service user, staff will explain that it is time for their medication and clarify what is being given (especially if multiple tablets – e.g. “Here are your morning medications: your blood pressure pill and vitamin, as prescribed”). Even if consent is implied in the care plan, staff still confirm the person’s willingness at that time (“Would you like to take your medications now?”). This gives the service user an opportunity to ask questions or express any concerns (like “I feel too nauseous to take it right now”). If the person expresses reluctance or refuses, staff will not proceed to force the medicine. Instead, they will follow the refusal protocol (see Consent section above: e.g. try a bit later, address any issues, and inform healthcare providers if needed).

4. Administration Technique: The staff member will administer the medicine according to its prescribed route and best practice technique. For oral solid medications, this typically means handing the tablets/capsules to the resident (or placing in a medication cup) and offering fresh water to help swallow. Staff remain with the person until they are sure the medication is swallowed, to confirm it has been taken (especially important for those who might pocket or spit out pills). For liquid medicines, the dose will be measured at eye level in an oral syringe or medicine cup to ensure accuracy. Topical medications (creams, patches) will be applied with consent and as directed, maintaining the person’s dignity (e.g. covering exposed areas not being treated). Inhalers, eye/ear/nose drops, injections, or other specialised forms will only be administered by staff who have been specifically trained and deemed competent for those routes. If a medication must be administered via a clinical procedure (like a feeding tube or injection), this may be done by a nurse or by a care worker under delegation from a healthcare professional, according to our local policy and training requirements. We ensure that any such specialised administration (like insulin injections by a non-nurse care worker) is supported by appropriate training and written authorization (as per the NHS delegation protocols or local policy).

5. Observing the Service User: During and after giving the medication, staff will observe the service user for any immediate reactions or difficulty. For example, ensure the person swallows tablets without choking, check that a transdermal patch adheres well, or note if the person shows any adverse reaction (like coughing, allergic signs, etc.). If the person appears to have an adverse reaction or suddenly feels unwell after a medication, staff will seek medical help promptly and follow emergency procedures as necessary. Any adverse drug reaction noted will also be reported to the GP/prescriber for review.

6. Documentation: Immediately after administering each medication, the staff member signs the Medication Administration Record (MAR) to confirm that the dose has been given. (We never sign before giving the medicine, only after we have witnessed it being taken, to ensure accuracy.) The MAR entry includes the date and time of administration, the name of the medication and dose (pre-printed on chart), and the signature/initials of the staff who administered it. If any dose was omitted or refused, or given late, the staff records the appropriate code and notes the reason (e.g. “R” for refused, with an explanatory note like “refused, will try later and informed GP if continues” in the care notes). For “when required” (PRN) medications, staff will record not only the giving of the medicine but also the reason it was needed (e.g. “Paracetamol given at 2pm for headache”) and later the outcome/effect if observable (to help evaluate effectiveness). All records are kept clear and legible, whether on paper MAR sheets or electronic MAR systems, as these are critical for communication and audit.

7. After Care and Follow-up: Staff ensure that the service user is comfortable after taking their medication – offering further assistance like ensuring they have water, or helping them get to a comfortable position if a medicine might cause dizziness, etc. If the medication has specific after-care (e.g. remain upright for 30 minutes after an alendronic acid tablet), staff will remind and assist the person with this. We also note any immediate issues; for instance, if a person vomits shortly after taking a medication, we document this and inform a senior staff or GP for advice on whether to repeat the dose.

8. Handling Refusals or Difficulties: In cases where the service user does not take the medication (refuses or spits it out), staff do not force or conceal it (unless a covert plan is in place as described earlier). Each refusal or mishap is recorded and reported appropriately. Staff may attempt to give the medicine again a short while later if the person agrees, or at a different time (with medical advice if needed to ensure safe timing). Persistent refusal is escalated for medical review. Under no circumstance will staff hide medication in food or drink without a proper best-interest decision and covert medication plan (see Consent section).

9. Special Circumstances:

“As Required” (PRN) Medication: For PRN medications (like painkillers or anxiety medication that are not scheduled at fixed times), there will be an individual protocol in the care plan indicating when these should be offered or administered (for example, signs of pain to look for if the person cannot verbalize, minimum time gaps between doses, maximum doses per day). Staff will use their judgment within these guidelines to determine if the PRN is needed, then document why it was given and the result. If PRN medicines are needed very frequently or not effective, the staff will inform the GP to review the treatment.
Controlled Drugs: Some prescribed medications are controlled under the Misuse of Drugs Act (e.g. certain strong painkillers like morphine). These have additional legal storage and administration requirements. All controlled drugs (CDs) in the care home are kept in a locked Controlled Drugs cabinet, and a Controlled Drug Register is maintained for each receipt, administration, and disposal. When a controlled drug is administered, it must be witnessed by a second trained staff member for accuracy and safety, and both staff sign the CD register (as well as the MAR chart) to confirm the dose. We count controlled drug stock at each administration and regularly (e.g. each shift change) to quickly detect any discrepancies. If a service user is self-medicating a controlled drug (which is rare and would only happen after careful risk assessment), we still maintain oversight as per law (possibly keeping a portion in the CD cupboard and giving the person small supply at a time, depending on the plan).
Insulin and Other Injections: For residents who require insulin or other injectable medications, a qualified nurse will normally administer these in a nursing home. In a residential home without on-site nursing, either community nurses will visit to administer, or care staff may do so only if specifically trained and competency-assessed for that task under a clear delegation protocol. The same applies to tasks like administering through a PEG feeding tube or other specialised routes – staff will follow the relevant clinical guidelines and our policy on delegated healthcare tasks.
Covert Administration: If covert administration (giving medicine in food/drink without the person’s knowledge) is authorised via a best-interest process (for a person who lacks capacity and refuses vital medication), staff will administer accordingly but with meticulous adherence to the plan. Each covert administration is recorded on the MAR with a special code and details in the care notes (e.g. “Covertly given in yogurt as per best interests plan”). The plan will include guidance from a pharmacist or GP about how to give that medication covertly (e.g. which foods it can be mixed with, ensuring it’s given fully). These situations are rare and carefully monitored.

By following these procedures, we ensure that when staff administer medication directly, it is done safely, correctly, and in the best interest of the service user. Medication administration by staff is also only done if the care plan clearly indicates this level of support is required. (If a care plan suggests a person could self-administer with prompting, we would not routinely take over and administer unless the person’s condition warrants it or they request it. Any changes would prompt a care plan update.) Staff understand their accountability in this role – if they administer a medicine incorrectly, they must report it (even if no apparent harm, as a “near miss” or incident) so we can learn and prevent future errors. All staff involved in medication administration must remain vigilant and double-check each step, especially when handing over duties during shift changes or when dealing with new prescriptions.

Medication Administration Records (MAR) and Documentation

Accurate record-keeping is a vital part of our medication management. Each service user has a Medication Administration Record (MAR), which may be a paper MAR chart or an electronic MAR system used by the home. The MAR is the formal log of all medications prescribed and the administration (or offering/assistance) of those medications. Key points about our MAR and documentation process:

MAR Chart Contents: The MAR chart lists all current medications for the service user, including drug name, form, strength, dosage instructions, route, and timing, as well as space to sign for each administration. It also includes the person’s name, date of birth, any known allergies, and sometimes a photograph for ID (especially in paper MAR charts) to ensure right identity. For each medication, the MAR indicates whether it is regular (scheduled doses), PRN (“as needed”), or a short course, etc. Non-prescribed homely remedies that the home might give are also documented on the MAR when given, to maintain one comprehensive record.
Signing for Medication: Staff administering or assisting with medication will sign the MAR immediately after the medication is taken or given. Each staff signer has a full signature and initials recorded on a signature log for identification. If two staff are involved (e.g. for controlled drugs or double-checking doses), both sign as required. Electronic MAR systems will log the user’s identity automatically.
Codes and Explanations: We use standard coding on MAR for when a dose is not given exactly as prescribed. For example, common codes: R = Refused, O = Omitted (with reason), X = Hospital (not in home), P = Person self-administered (or “prompted”) depending on system, etc. Our policy details the codes used and staff write a brief reason in the notes section (or electronic comment) for any code. E.g., “R – refused, complained of stomach ache – will monitor and try later.” If a dose is given late or outside the prescribed time window, this is also noted (and reason if applicable, e.g. “late – resident at hospital appointment, given at 3pm instead of 2pm”). These notes ensure anyone reviewing the MAR understands any variance.
Recording Non-Prescription Medications: Any over-the-counter remedy or supplement given by staff is recorded on the MAR just like a prescribed medicine. We either add it to the MAR (with clear indication it’s a homely remedy/OTC) or use a separate homely remedies administration record that is cross-referenced. Details include the product name, dose, time, and reason for giving, as well as the staff signature. If a resident self-takes an over-the-counter product independently but we are aware (for example, they have their own supply of herbal tablets), we document in the care plan and notes that they are using this and encourage them to inform staff each time they take it so it can be noted – this helps us monitor for interactions or duplicate therapy.
Daily Notes and Handover: Significant medication-related information is also recorded in the shift daily notes and handed over between shifts. For instance, if a PRN was given for high blood pressure, or a dose was missed, or a side effect observed, this will be highlighted in the handover so that incoming staff are aware and can follow up. We maintain that “details of all medication, prescribed and non-prescribed, must be formally passed on between duty staff at every handover” to ensure continuity of care.
Medication Changes: When there is a change in a medication (new prescription, change in dose, or discontinuation) from the doctor, two trained staff will, whenever possible, check the new instructions and update the MAR accordingly to avoid any transcription errors. We attach the new prescription or the GP’s written communication to the MAR for reference until the pharmacy issues a updated printed MAR. If electronic MAR is used, it will be updated by authorised personnel and double-checked. All old MAR entries that are discontinued are clearly crossed out (with date and signature) to avoid accidental administration.
Auditing Records: The home conducts regular audits of MAR charts – e.g. a senior staff or manager reviews completed MARs at least monthly (or more frequently) to check for any missed signatures, errors, or patterns (like frequent PRN use or refusals). Any discrepancies (e.g. unsigned entries, inventory count mismatches) trigger an investigation to identify the cause (whether it be a recording lapse or an actual missed dose) so that it can be rectified. We retain completed MAR charts and medication records for an appropriate period (minimum 3 years as recommended for adult care services) securely, after which they are disposed of confidentially.

Maintaining accurate MAR and records is not only a regulatory requirement but also a crucial part of safe care – it provides a continuous medication history for each service user and is our primary tool for communication among care team members regarding medication administration.

Prescribed Medications vs. Non-Prescribed (Homely Remedies)

Our policy covers both prescribed and non-prescribed medicines to ensure safety in all cases.

Prescribed Medications: These are medications ordered by a licensed prescriber (GP, hospital doctor, dentist, etc.) specifically for a service user. We only administer or assist with prescribed medicines if there is a clearly written direction (label/instruction) for use. Staff must check that each medication has a proper pharmacy label with the person’s name, drug, dose, and instructions – if any medication is ever received without clear labelling (for example, a hospital discharge medication that is unclear), staff will clarify with a pharmacist or doctor before giving. We never alter doses or schedules of prescribed meds without medical direction. If a service user’s condition seems to warrant a change (e.g. increased pain not controlled by current analgesic), we contact the GP rather than adjusting medication ourselves. We also ensure medication reviews are conducted by the prescribing clinicians at appropriate intervals (typically every 6 or 12 months, or sooner if needed) to confirm that each medicine is still appropriate. Staff will facilitate these reviews by providing information on how the resident is doing with their meds (for instance, noting any side effects or effectiveness issues).

Non-Prescribed Medications (Over-the-Counter and Homely Remedies): Non-prescribed items include things like mild pain relievers, cough syrup, indigestion tablets, herbal remedies, vitamins, etc., that a person might normally buy for themselves. Even though these do not require a doctor’s prescription, in a care home setting we handle them carefully to avoid harm. Our approach to homely remedies (common OTC medicines kept for minor ailments) is as follows, in line with NICE guidance:

We have a homely remedies protocol approved by our organization which lists what over-the-counter medicines may be considered, for what minor conditions, and the instructions for their use. For example, the protocol might allow paracetamol for mild pain or fever, an antacid for indigestion, or simple linctus for cough. The protocol clearly states the indications (ailments) for each product, the name of the product and strength, the dose and frequency, and the maximum duration it can be given before a doctor must be consulted. It also lists any contraindications – for instance, if a resident is already on a prescribed medication containing paracetamol, we must not give additional OTC paracetamol without medical advice.
We require that a manager or designated senior staff authorises each use of a homely remedy for a particular resident. The staff member will check the protocol, ensure the resident has no contraindication (including checking their current prescribed meds for interactions or duplications), and then document the administration on the MAR and in a homely remedy record. We include the date, time, reason (symptom) and outcome. We also note how many doses have been given and when to stop or seek medical review. Typically, if a homely remedy is needed beyond a short period (e.g. 48 hours or the maximum specified in our protocol), staff will contact the GP for advice.
Only trained staff are permitted to administer homely remedies, the same as for prescribed meds. Those staff are named in the homely remedy process documents and they sign to indicate they are competent and accountable for this task. This ensures accountability that the person giving an OTC remedy knows what they are doing and will take responsibility.
All homely remedy stock is kept securely, just like prescribed drugs, and we check expiry dates regularly. We also record homely remedy usage in a way that can be audited (so we know how much of a product was used, by whom, and for whom). If an OTC medicine does not help the condition or if the condition worsens, staff will stop the homely remedy and arrange for a medical assessment.

In addition to homely remedies provided by the care home, some service users (or their families) may wish to use herbal or alternative supplements on their own. We do not encourage unsupervised use of such products because of potential risks, but we respect personal choice. Our policy is that any herbal or non-prescribed supplement a resident brings or asks for should be discussed with the GP or pharmacist to ensure there are no known harmful interactions with their prescribed medications. If approved, we will document it in the care plan and MAR (so it’s known and recorded when taken). If a healthcare professional advises against a particular supplement due to safety, we will communicate this to the service user and come to an understanding (potentially asking family to refrain from providing it). The safety of the service user is our priority, so all substances they ingest as part of their care are subject to oversight.

By having clear guidelines for both prescribed and non-prescribed medications, we ensure that all medications (regardless of source) are treated with the same level of caution and documentation. This prevents situations such as double-dosing (taking a prescribed drug plus an OTC of the same ingredient unknowingly) and ensures the GP remains aware of everything the resident is taking.

Ordering, Receiving, Storage, and Disposal of Medicines

Proper systems are in place to manage the medication lifecycle in the home – from ordering new stock to disposing of unused doses – so that medicines are available when needed and handled safely at all times .

Ordering Medicines: {{org_field_name}} uses a reliable process (usually a monthly cycle, with interim orders as needed) to reorder prescribed medications in a timely fashion. A designated staff (e.g., senior carer or medication lead) will coordinate with the service user’s GP and a pharmacy of the service user’s choice (or our usual pharmacy supplier) to prepare repeat prescriptions. We maintain an ordering log where we record what was ordered (drug name, strength, quantity) and the date ordered. When medications are delivered from the pharmacy, staff check the delivery against the order to ensure all items are received and correct. Any discrepancies (missing items or wrong items) are noted and promptly followed up with the pharmacy and GP if necessary. For new acute prescriptions, we aim to obtain them the same day or as soon as possible; staff may need to pick up the prescription or arrange urgent delivery. We also have procedures for emergency medications or prescriptions outside normal hours, including contacting out-of-hours services or using an emergency pharmacy supply if needed (documented in our business continuity plans).

Receiving and Checking: Upon receiving medications from the pharmacy, two staff members (when possible) will check the medications in. They verify labels (right resident, medicine, dose), quantity supplied, and note expiry dates. Any controlled drugs are entered into the Controlled Drug Register at the time of receipt with a witness. If we receive a printed MAR chart from the pharmacy, staff will cross-check it with the received medicines and the previous MAR to ensure continuity (any changes are noted). The received stock is then stored appropriately immediately. We ensure secure transport of medicines – if staff collect medicines or transport them, they carry them in a secure, sealed container and go directly to the home. (If there are multiple stops, a risk assessment is done to keep medicines secure and temperature-controlled, particularly for items like refrigerated insulin).

Storage: All medications in the home are kept securely and under the recommended conditions:

Medication Trolleys/Cabinets: Routine medications are stored in locked medication trolleys or locked cupboards in a designated medication room/area. These storage units are kept locked when not in use, with keys held by the senior staff or nurse on duty. Each service user’s medicines may be compartmentalised within the storage (e.g., individual baskets or sections for each person) to reduce risk of mix-up.
Room Temperature Control: Medicines are stored at appropriate room temperature, away from heat and direct sunlight. We monitor the medication room temperature if needed to ensure it stays within safe limits (generally below 25°C for most medications). If temperatures exceed limits, we take action like moving stock or using fans – and in any case, ensure the pharmacy advice is followed for any heat-sensitive drugs.
Refrigerated Medicines: Any medicine that needs refrigeration (typically 2-8°C, such as certain insulin, eye drops, some antibiotic liquids) is kept in a dedicated medicine refrigerator which is lockable or within a locked room. The fridge temperature is monitored daily and recorded to ensure it remains in range. We have a protocol for what to do if the fridge goes out of range (e.g., contact pharmacy to determine usability of meds, possibly discard if unsafe).
Controlled Drugs: As mentioned, controlled drugs have a separate locked CD cupboard (complying with Misuse of Drugs Safe Custody requirements) securely fixed to a wall. Only authorised staff have access to the CD keys, and keys are kept on a person (not left unattended).
Self-Administered Medication Storage: For those who self-administer, as discussed in the self-administration section, their medicines may be stored in their own room in a secure manner (like a lockable drawer). We still consider overall security; for example, a resident’s room is private, but we ensure any risk of other residents accessing is mitigated.
Separation and Organization: External use medications (creams, ointments, eye drops) are often stored separately from internal medications to avoid errors. Disinfectants or other care products are not stored with medications. Each item is kept in its original container with original labels – we do not transfer medications between containers. If we use compliance aids (like blister packs or dosette boxes), these are prepared by the pharmacy whenever possible (not by our care staff, except in unusual one-off circumstances with appropriate risk assessment).

We keep a stock record or running balance for medications if needed, particularly for controlled drugs and sometimes for other high-risk meds or when auditing. At each administration, staff note if they give the last dose in a box or if stock is running low, so re-orders can be timely.

Disposal of Medications: When medications are no longer needed or safe to use, we dispose of them in accordance with legal requirements and environmental safety:

Discontinued or Expired Meds: Any medication that is discontinued by the prescriber, or expired, or belongs to a service user who has passed away or left the home, is removed from active stock promptly. We record these in a returns log, noting the medication name, quantity, and the reason for disposal (e.g. “discontinued by GP” or “expired”). These medicines are stored in a separate, secure “to be disposed” area until collected or taken to the pharmacy. We then either return them to the pharmacy for safe disposal (preferred method for most medications) or, where protocol allows, use approved disposal methods (like a medicines destruction kit, especially for controlled drugs).
Controlled Drugs Disposal: Controlled drugs require special handling for disposal. We denature (chemically inactivate) controlled drugs using a kit (CD destruction kit) in the presence of an authorised witness (this could be the pharmacist or a police officer or our own manager if appropriately authorised, depending on local arrangements). A record is made in the Controlled Drug Register of the disposal, signed by two witnesses. Often, community pharmacists will come to the home to witness and collect CDs for destruction. We never throw medications (especially CDs) into general waste or flush them down toilets, as this is both unsafe and illegal.
Sharps and Patches: Any sharps (like used epi-pens, insulin pen needles) are disposed of in sharps containers following clinical waste protocols. Transdermal patches (which may still contain drug after use) are folded and disposed of carefully (we handle these as clinical waste to avoid drug exposure to others).
Household Waste: We understand that medicines should not go into normal waste. Our home uses designated pharmaceutical waste bins (often supplied by the pharmacy) for any medication waste, which are then collected by a licensed waste contractor or via the pharmacy.
Recording Disposal: For each batch of medicines sent for disposal, a record is kept (some pharmacies provide a receipt). We document the date, what was disposed, and who handled the handover. This recordkeeping is important for audit trails and to ensure accountability that medicines are not being misused. CQC expects providers to record the date of disposal, the name/quantity of medicines, and who they were returned to (which pharmacy) – our practice meets these expectations.

Through careful ordering, secure storage, and proper disposal, we ensure medicines are available in sufficient quantities, managed safely, and not allowed to pose risks (such as someone taking an old or wrong medication).

Medication Errors and Incident Reporting

Despite robust procedures, there is always a risk of medication errors or incidents. An error might include giving a wrong dose, missing a dose, giving the wrong medication or to the wrong person, administering at the wrong time (significantly early/late), or discovering a recording discrepancy that suggests a dose may have been given incorrectly. It could also include incidents like a service user being given a medication they are allergic to, or a medication being found on the floor (meaning the resident possibly dropped or didn’t take it). Additionally, “near-misses” (where an error was caught before the medication was given) are important to capture.

Our policy is to treat all medication errors or near-misses seriously and use them as a learning opportunity to prevent future incidents. The following steps are taken in the event of a medication-related incident:

Immediate Response: The priority is the well-being of the service user involved. If an error is identified after a medication has been administered (for example, the wrong dose was given), the staff member will immediately assess the potential impact. If it could be harmful, they will seek medical advice without delay – e.g., call NHS 111 or the GP (or 999 if the person’s condition is deteriorating) and follow any instructions (such as monitoring vital signs, giving fluids, etc.). Some errors may require specific treatment (antidotes) or observation. The service user and their next-of-kin (if appropriate) will be informed of the incident and any needed medical follow-up (in line with Duty of Candour requirements). If the error is identified before the person takes the medicine (a near-miss), the medicine is withheld and corrected, and no harm comes to the person, but we still address the cause.
Informing Management and Healthcare Professionals: Staff must report any medication error immediately to the senior on duty or manager. The manager will ensure appropriate actions are taken, including contacting the GP or emergency services as needed. If the error involves a prescription issue (like pharmacy dispensed the wrong medication or instructions), the pharmacy is contacted as well to prevent recurrence.

How to Report:

Verbally report the concern immediately to the Manager ({{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}).
Send an email detailing the concern to the Registered Manager at: {{org_field_registered_manager_email}}.
Call the office to inform the Registered Manager at {{org_field_phone_no}}.
If the concern arises out of office hours, call the out-of-hours phone number: {{out_of_hours}}.
Website: {{org_field_website}} – using the contact form provided

Documenting the Incident: An incident report form is completed as soon as possible (and within 24 hours) detailing exactly what happened, the medication(s) involved, doses, the people involved, observed effects on the service user, and actions taken. This internal record is used for investigation and kept on file. The MAR chart is also annotated to reflect what actually occurred (for transparency in the record).
Notifying CQC/Authorities: If the medication error constitutes a serious incident or safeguarding issue (for example, significant harm came to a resident or there was deliberate misuse), the Registered Manager will notify the appropriate authorities. CQC requires notification of some medication incidents, especially those that result in harm or have potential for abuse. Safeguarding referrals to the local authority may be made if the error was due to neglect or abuse. We follow the local safeguarding protocol and CQC notification guidelines in these instances. Staff are also aware of the need to be open and honest about mistakes as part of the Duty of Candour – apologizing to the resident/representatives and explaining the actions being taken.
Investigation and Analysis: The manager (or designated investigator) will look into the circumstances of the error to determine root causes. This might involve interviewing staff, reviewing MAR charts and procedures, checking training records, etc. We aim to find out whether it was a one-time slip/lapse or a systemic issue. For example, was the staff member exhausted or interrupted? Was the MAR chart unclear? Was staffing sufficient during the medication round? Each factor is considered.
Learning and Prevention: Based on the findings, the home will implement measures to prevent a similar error. This could include retraining the staff involved, updating this policy or procedures, improving the MAR chart layout, increasing double-checks for certain meds, or disciplining staff if it was due to negligence or not following policy. We may arrange an external competency assessment if needed. All staff are briefed on lessons learned in staff meetings or memos (without blaming individuals – focusing on improvement). For instance, if a mix-up occurred because two residents have similar names, we might institute an extra check (like highlighting names on MAR or adding photos to MAR).
Monitoring Post-Error: After an error, the manager might increase supervision of medication rounds for a period or conduct an audit to ensure the fix is working. The staff involved might be observed administering by a senior to confirm competence. If a staff member makes repeated errors, even after retraining, further action is taken (e.g. they may be taken off medication duty and possibly face disciplinary action, as a last resort, because resident safety is paramount).
Open Culture: We promote a culture where staff can report errors or near-misses without fear of unjust punishment – encouraging reporting and honesty leads to better safety. Deliberate or reckless behavior, however, is not tolerated. All medicine-related incidents (including near misses) are recorded and reviewed periodically to see trends and ensure continuous improvement.

In summary, any medication error is promptly addressed to ensure the service user is safe, reported to management and relevant bodies, and thoroughly investigated. We comply with the CQC expectation that medication-related safeguarding incidents are reported and dealt with properly. These steps help us maintain trust, improve our systems, and ultimately deliver safer medication support.

Staff Training and Competency

Medication assistance and administration is a high-risk activity in social care, so we enforce strict requirements for staff training and competency assessment. Only staff who have completed the necessary training and demonstrated competence are allowed to handle medications (whether it’s prompting, assisting, or administering). Key points of our training and competency program:

Initial Training: All new care staff receive medication training as part of their induction (commensurate with their role). This generally includes a taught course (e.g. Medication Awareness or Safe Handling of Medicines in Care) covering the basics of pharmacology, the 6 rights of administration, how to read labels and MAR charts, infection control, documentation standards, managing controlled drugs, understanding side effects, the importance of consent, and what to do in event of errors. For trained nurses, their professional training covers medication administration, but they still undergo an orientation to our specific policies. We aim to use accredited training providers and ensure the content meets CQC and regulatory standards.
Specialised Training: If staff will be involved in specialised tasks (like administering insulin, using a feeding tube, giving eye drops, etc.), additional targeted training is provided either by healthcare professionals (district nurse, pharmacist) or through accredited courses. For example, only staff trained in diabetes care and insulin administration can be assigned to give insulin injections. Similarly, training on use of epi-pens for allergic reactions, or on oxygen therapy, etc., is arranged as needed for individuals’ care.
Competency Assessment: Training alone is not enough; each staff member must be assessed as competent in medication tasks before they can work independently. Our competency assessment involves a qualified person (like a senior staff, manager, or external assessor) observing the staff member during medication rounds and checking their knowledge via questions or written tests. We use a competency checklist that covers critical points (e.g. does the staff check identity, follow 6 rights, sign MAR correctly, handle refusals properly, etc.). They may need to demonstrate measuring liquids, using inhalers, etc. Only when the assessor is satisfied that the staff can perform error-free and confidently, do we allow that staff to administer medications unsupervised. If a staff does not meet the standard, they will not administer meds and will receive further training or mentoring until competence is achieved. Staff must sign to acknowledge their responsibilities, and the manager signs off their competency.
Ongoing Training (Refresher): We require all care staff who administer or assist with medication to undergo annual refresher training and competency re-assessment. This keeps knowledge up to date (for example, if guidelines change or new forms of medication become common) and reinforces good practice. Additionally, if at any time a medication-related incident suggests a knowledge gap or skill issue, the staff involved will receive extra training promptly, without waiting for the annual update. Our training program is designed to meet requirements of regulators (CQC expectations, Health and Safety, etc.) and the needs of our residents.
Record of Training: {{org_field_name}} maintains a training matrix and individual staff training records showing when medication training and competency checks were completed and when renewals are due. The Manager monitors this to ensure no one falls out of compliance.
Supervision and Spot Checks: Beyond formal training, we incorporate medication management into staff supervision and appraisals. The manager or senior staff may perform spot checks or observations of medication rounds periodically to ensure procedures are being followed. Any deviations or bad habits can be corrected through coaching. We also encourage staff to speak up if they feel unsure or if they think they need more training in any aspect of medication (for example, if a new PEG feed procedure is introduced and they have not done it before).
Knowledge Updates: We provide resources and updates to staff when new guidance or best practices emerge. For instance, if NICE updates a guideline or if there are new high-risk medications introduced in the home, we might do a focused in-service training or distribute reading material. We also cover medication topics regularly in team meetings to keep awareness high (like reminding about checking expiry dates, or discussing common side effects seen in our residents).

By ensuring rigorous training and assessment, we align with the requirement that staff only administer medicines when they have the necessary training and have been assessed as competent. No staff member is allowed to “learn on the job” with real medications without oversight; they must first prove competency. This protects our service users and gives confidence that those assisting them with medication are qualified to do so.

Policy Review and Compliance

This Medication Assistance policy will be reviewed at least annually or sooner if there are changes in relevant legislation, CQC requirements, or significant learning from incidents. The Registered Manager is responsible for ensuring the policy remains current and reflective of best practices. Reviews will take into account any updated guidance from sources such as the CQC, NICE, the Royal Pharmaceutical Society, and changes in the law (for example, updates to the Medicines Act or controlled drugs regulations). Staff will be notified of and trained on any changes in the policy. We maintain a version history of the policy with dates of revisions.

Compliance with this policy is monitored through regular audits (of MAR charts, storage conditions, etc.), supervision of staff, and feedback from service users and relatives. The management will also routinely spot-check that care plans correctly document medication support levels and that practice matches the plan (for example, if a care plan says a person self-medicates with prompts, we ensure that prompts are indeed given and recorded appropriately). We also welcome input from pharmacists (e.g., periodic medication audits or reviews by our supplying pharmacy) to improve our systems.

Ultimately, by adhering to this policy, {{org_field_name}} ensures that service users receive their medications safely, effectively, and in the manner that best supports their independence and well-being. This policy supports compliance with CQC’s fundamental standards – in particular, that there are clear policies and staff training in place for medicines, and that people get their prescribed and non-prescribed medicines as intended, with appropriate records and protocols. Through continuous improvement and vigilance in medication management, we strive to protect our residents and help them achieve the best health outcomes.

Sources:

Care Quality Commission (CQC) Guidance for Providers – Managing Medicines in Care Settings, including expectations that services support people to manage their own medicines where possible and ensure proper administration of both prescribed and non-prescribed medicines .
National Institute for Health and Care Excellence (NICE) Social Care Guideline SC1 – Managing Medicines in Care Homes, which outlines best practices for medicines policy development, self-administration, covert administration, use of homely remedies, record-keeping, and staff training.
CQC Fundamental Standards – Regulation 12: Safe Care and Treatment, requiring safe management of medicines to prevent harm .
CQC online guidance: Self-Administered Medicines in Care Homes (2022) – emphasizing the right to independence in managing medication and the need for risk assessments, secure storage, support, and records for self-medication .
NICE Guideline NG67 – Managing Medicines for Adults Receiving Social Care in the Community – which covers assessing medicine support needs and staff training for home care (principles also applicable to care homes).
iHasco “Guide to Administering Medication in Care Homes” – summarizing the importance of robust medicines policies, the six rights of administration, risk assessment for self-medication, and thorough record-keeping and oversight of medication management .

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