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CHW45-Assisting Service Users with Medication Policy

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Registration Number: {{org_field_registration_no}}

Assisting Service Users with Medication Policy

1. Purpose

The purpose of this policy is to ensure that all medication management and administration at {{org_field_name}} is carried out safely, legally, and in line with best practice. The policy aims to protect service users from harm, promote independence where possible, and ensure compliance with all regulatory and legislative requirements.

This policy sets out the systems used by {{org_field_name}} for the safe management and oversight of medicines, including assessment of medication support needs, ordering, re-ordering, receipt, reconciliation, storage, administration, covert administration, self-administration, recording, monitoring, disposal, audit, incident reporting and learning. The policy applies to prescribed medicines, controlled drugs, homely remedies, topical preparations, nutritional supplements, oxygen, medicines requiring refrigeration, time-sensitive medicines, variable-dose medicines, “when required” medicines and medicines administered by specialist routes where these are part of a service user’s care and support.

This policy aligns with:

2. Scope

This policy applies to:

The policy covers:

3. Principles of Safe Medication Management

3.1. Person-Centred Approach to Medication Support

At {{org_field_name}}, we support service users to take medication in a way that:

Each service user’s medication needs are assessed upon admission, and a Personal Medication Plan (PMP) is developed in collaboration with healthcare professionals and, where appropriate, family members.

Medication support needs must be recorded in the service user’s personal plan and must include the level of support required, the service user’s preferences, communication needs, consent, capacity considerations, allergies, known side effects, swallowing difficulties, cultural or religious considerations, preferred routines, self-administration arrangements, risks and any specific instructions from the prescriber, pharmacist, GP, community nurse or other relevant healthcare professional.

The personal plan must be reviewed whenever medication is started, stopped, changed, refused repeatedly, administered covertly, involved in an error, or where there is a change in the service user’s health, capacity, risk, level of independence or medication support needs.

3.2. Ordering, Re-ordering, Receipt and Reconciliation of Medicines

{{org_field_name}} will maintain a safe system for ordering, re-ordering, receiving and reconciling medicines to ensure that service users have a sufficient supply of prescribed medication at all times.

Medication ordering and re-ordering will only be undertaken by authorised and trained staff. Staff responsible for ordering medicines must check current MAR charts, medication stock, recent prescription changes, hospital discharge information, GP or prescriber instructions and pharmacy records before placing an order.

Medicines must be ordered in sufficient time to avoid missed doses. Staff must take prompt action where a medicine is unavailable, out of stock, delayed, missing, discontinued or unclear. This may include contacting the pharmacy, GP, out-of-hours service, prescriber, community nurse, NHS 111 Wales or emergency services, depending on the level of risk.

On receipt of medicines, authorised staff must check the medicines against the prescription, MAR chart, delivery note and expected order. Any discrepancy must be investigated immediately and recorded. Medicines must not be administered where there is uncertainty about the medicine, dose, route, timing, service user identity or prescriber instruction.

A medication reconciliation must be completed when a service user is admitted, returns from hospital, attends outpatient appointments, has medicines changed, transfers between services, or returns from home leave. Reconciliation must confirm the current medicines, dose, route, timing, reason for use where known, allergies, discontinued medicines and any outstanding queries.

Any discrepancy identified during ordering, receipt or reconciliation must be escalated to the Registered Manager or senior person on duty and resolved with the pharmacist, GP, prescriber or relevant healthcare professional before administration, unless urgent clinical advice confirms otherwise.

3.3. Safe Medication Storage and Handling

All medicines must be stored securely, safely and in accordance with the manufacturer’s instructions, the prescriber’s directions, pharmacy advice and current legislation or guidance.

Medicines must be stored in a locked medication trolley, locked medication cupboard, locked clinical room, locked refrigerator or other approved secure storage appropriate to the medicine and the service user’s needs. Access must be restricted to authorised staff only.

Controlled drugs must be stored in a controlled drugs cabinet that meets legal requirements and must be recorded in the controlled drugs register.

Medicines requiring refrigeration must be stored in a designated locked medication refrigerator. Fridge temperatures must be checked and recorded daily when in use. Any temperature outside the recommended range must be escalated immediately to the Registered Manager or senior person on duty and advice must be sought from the supplying pharmacy or prescriber before the medicine is used.

Room temperatures for medication storage areas must be monitored and recorded in accordance with local procedure. Any concern that medicines may have been stored outside recommended conditions must be escalated and pharmacy advice obtained.

Medicines must remain in their original packaging wherever possible and must not be transferred into another container unless this has been authorised by the pharmacist or prescriber and is part of an agreed safe system.

Medicines must be stored separately where required, including internal medicines, external preparations, controlled drugs, refrigerated medicines, medicines awaiting return or disposal, homely remedies, self-administered medicines and medicines belonging to individual service users.

Staff must check expiry dates, opening dates and storage instructions. Items with limited expiry after opening, such as eye drops, creams, liquids and insulin, must be dated when opened and disposed of when expired.

Medication trolleys, cupboards, refrigerators and clinical storage areas must be kept clean, organised and free from avoidable contamination. Medication keys must be held securely by authorised staff and must not be left unattended.

3.4. Administration of Medication

All medication administration follows a safe and structured process to minimise errors and ensure compliance with prescriptions. Our staff adhere to the “Six Rights” of medication administration:

  1. Right Service User – Confirm identity before administration.
  2. Right Medication – Ensure the correct prescription is given.
  3. Right Dose – Check dosage instructions and measure accurately.
  4. Right Route – Administer via the correct method (oral, topical, injection, etc.).
  5. Right Time – Administer at the correct prescribed times.
  6. Right Documentation – Record all medication given, including any refusals.

Staff must only administer medicines when they are trained, competent and authorised to do so. Before administration, staff must check the service user’s identity, the MAR chart, the medicine label, dose, route, time, expiry date, allergies, special instructions and any relevant personal plan guidance.

Medicines must be administered directly from the container supplied by the pharmacy or in accordance with the agreed local procedure. Staff must not administer from memory or from handwritten changes unless the change has been verified and authorised in line with this policy.

Where there is any uncertainty, including unclear directions, missing labels, conflicting information, omitted signatures, suspected adverse reaction, refusal, swallowing difficulty, or concern that the medicine has been altered or contaminated, staff must not proceed until advice has been obtained from the pharmacist, GP, prescriber, community nurse or other appropriate healthcare professional.

Medicines must be recorded on the MAR chart immediately after administration. Staff must not pre-sign MAR charts. If a medicine is not administered, the correct non-administration code and reason must be recorded, and appropriate follow-up action must be taken.

Time-sensitive medicines, including medicines for Parkinson’s disease, epilepsy, diabetes, pain control, anticoagulation or end-of-life care, must be administered at the prescribed time unless clinical advice states otherwise. Any delay or omission must be escalated according to the level of risk.

Variable-dose medicines must only be administered where the MAR chart or prescriber instructions clearly state the dose to be given and the circumstances for giving it. Staff must record the actual dose administered.

3.5. PRN and “When Required” Medicines

PRN medicines must only be administered where there is a clear PRN protocol in place. The protocol must be person-centred and must state the name of the medicine, reason for use, dose, route, minimum interval between doses, maximum dose in 24 hours, signs or symptoms that indicate the medicine may be needed, non-medicine interventions to try where appropriate, expected outcome, side effects to monitor, when to seek medical advice and when the medicine should be reviewed.

Staff must check the PRN protocol before administration and must record the reason for giving the medicine, the dose given, the time given and the outcome or effectiveness. Where a PRN medicine is used frequently, not used at all, appears ineffective, causes side effects, or is refused repeatedly, this must be referred to the GP, prescriber or pharmacist for review.

PRN medicines used for distress, anxiety, agitation, sleep or behaviour must not be used as a form of unlawful restraint or for staff convenience. Any use must be lawful, proportionate, in the service user’s best interests where they lack capacity, and in accordance with the personal plan and relevant professional advice.

3.6. Covert Administration of Medication

Covert administration means giving medicine in a disguised form without the service user knowing it is being administered. Covert administration must only be considered where the service user lacks capacity to make the specific decision about taking the medicine, the medicine is necessary, refusal places the person at risk of harm, and it has been agreed through a lawful best interests decision-making process under the Mental Capacity Act 2005.

Covert medication must never be used for staff convenience or simply because a service user refuses medication. A service user who has capacity has the right to refuse medication, even if others consider the refusal unwise.

Before covert medication is used, there must be a recorded mental capacity assessment, a best interests decision, consultation with relevant people, and written advice from the pharmacist or prescriber confirming how the medicine can be given safely, including whether it can be crushed, mixed with food or drink, or administered by another method.

The service user’s personal plan and MAR chart must clearly state the covert administration arrangements, including which medicines are authorised for covert administration, how they are to be administered, who authorised the arrangement, review dates and monitoring requirements.

Covert administration must be reviewed regularly and whenever there is a change in the service user’s capacity, health, medication, behaviour, risks or willingness to take medication openly.

3.7. Supporting Self-Administration

{{org_field_name}} will support service users to manage their own medicines where this is safe, appropriate and consistent with their wishes, capacity, assessed needs and personal outcomes.

A self-administration risk assessment must be completed before a service user self-administers medication. The assessment must consider the service user’s capacity, understanding of the medicine, ability to order and store medicines safely, ability to take the correct medicine at the correct time, risks to other people, history of overdose or misuse, cognition, dexterity, eyesight, swallowing, mental health, communication needs and any fluctuating needs.

The level of support must be clearly recorded in the personal plan. This may include full independence, prompting, supervision, staff ordering only, staff storage only, or full staff administration.

Service users who self-administer must have secure storage for their medicines. Staff must check, in line with the risk assessment, whether the service user continues to have sufficient supplies and whether medicines are being taken safely.

Self-administration arrangements must be reviewed at least monthly, and sooner if there are concerns, medication changes, errors, missed doses, deterioration in health or cognition, safeguarding concerns or a change in risk.

3.8. Controlled Drugs and Specialist Medications

Controlled drugs must be ordered, received, stored, administered, recorded, checked and disposed of in accordance with the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001, local pharmacy procedures and this policy.

Controlled drugs must be stored in the controlled drugs cabinet and recorded in the controlled drugs register. Entries must be made in chronological order and must include the date, time, service user, medicine, strength, dose, quantity received, quantity administered, quantity remaining, signatures of staff involved and any disposal or return details.

Wherever possible, two trained and competent staff should be present when controlled drugs are administered, recorded, checked or returned. Where this is not possible, the reason must be recorded and the procedure must still ensure safe administration and accurate stock balance.

Controlled drug stock balances must be checked at least weekly and whenever a discrepancy is suspected. Any discrepancy must be reported immediately to the Registered Manager or senior person on duty, investigated, recorded and escalated to the pharmacist, prescriber, safeguarding team, police or CIW where required.

Specialist medicines, including injections, insulin, anticoagulants, oxygen, transdermal patches, thickening agents, enteral feeds, rescue medicines, end-of-life medicines and medicines administered by specialist routes, must only be administered by staff who have received task-specific training and have been assessed as competent. The personal plan must include clear instructions, monitoring requirements, escalation actions and relevant professional guidance.

Transdermal patches must be applied, rotated, checked and removed in accordance with the prescriber’s instructions. Staff must record the site of application and must check that the previous patch has been removed unless otherwise prescribed.

3.9. Homely Remedies and Non-Prescribed Medicines

Homely remedies must only be used where {{org_field_name}} has an agreed homely remedies protocol authorised by an appropriate healthcare professional, such as the GP or pharmacist. The protocol must state which medicines may be used, indications for use, dose, maximum duration, contraindications, side effects, recording requirements and when medical advice must be sought.

Staff must check allergies, prescribed medicines, contraindications and the service user’s current condition before giving a homely remedy. Homely remedies must be recorded on the MAR chart or approved medication record.

Service users, families or representatives must not bring in over-the-counter medicines, herbal remedies, supplements or alternative preparations for use by the service user unless these have been checked and approved by the GP, prescriber or pharmacist and recorded in the personal plan and medication records.

3.10. Medication Errors, Near Misses and Adverse Reactions

A medication error includes any incident where a medicine is omitted, delayed, given to the wrong service user, given at the wrong dose, given by the wrong route, given at the wrong time, given without authorisation, continued after discontinuation, not recorded correctly, stored incorrectly, lost, spilled, refused without follow-up, or otherwise managed outside the prescriber’s instructions or this policy.

A near miss is an event that could have led to a medication error but was identified before harm occurred. Near misses must be recorded and reviewed so that learning can take place.

Where a medication error or near miss occurs, staff must take immediate action to protect the service user. This includes checking the service user’s wellbeing, seeking advice from the GP, pharmacist, NHS 111 Wales, prescriber, community nurse, emergency services or poison information service as appropriate, informing the Registered Manager or senior person on duty, recording the incident, informing the service user and/or representative where appropriate, and monitoring the service user in accordance with professional advice.

Medication errors must be investigated proportionately. The investigation must identify what happened, why it happened, whether the service user was harmed or placed at risk of harm, what action was taken, whether safeguarding or CIW notification is required, and what learning or practice change is needed.

Where the incident has caused harm, placed the service user at risk of harm, indicates neglect, abuse, improper treatment, unsafe systems, repeated errors or staff misconduct, the Registered Manager must consider safeguarding referral, CIW notification, professional referral and duty of candour requirements.

Staff must report suspected adverse drug reactions immediately. Emergency medical assistance must be sought where the service user has signs of serious allergic reaction, overdose, severe side effects, sudden deterioration or any other urgent clinical concern.

3.11. CIW Notification, Safeguarding and Duty of Candour

The Registered Manager and Responsible Individual must ensure that medication incidents are reviewed to determine whether they require notification to CIW, referral to safeguarding, reporting to the police, referral to a professional regulator, or action under the staff disciplinary procedure.

CIW must be notified in accordance with current notification requirements where a medication incident is notifiable, including where there is serious injury, death, suspected abuse, neglect, improper treatment, significant risk to a service user, repeated medication failures, or any event that affects the safe operation of the service.

Where a medication incident has caused harm or may have caused harm, {{org_field_name}} will act openly and transparently with the service user, their representative and relevant professionals. This includes explaining what happened, what immediate action was taken, what investigation or review will take place, the outcome of any investigation where appropriate, and any action taken to reduce the risk of recurrence.

Medication incidents will be reviewed as part of the service’s quality assurance systems, and themes, trends and learning will be shared with staff through supervision, team meetings, training, competency review and policy updates.

3.12. Consent, Choice, and Right to Refuse Medication

Service users must be supported to make informed decisions about their medicines wherever possible. Staff must provide information in a way the service user can understand, taking account of communication needs, language, cognition, sensory impairment and any need for advocacy or representative involvement.

A service user who has mental capacity to make a specific decision about medication has the right to refuse that medication, even where refusal may place them at risk. Staff must record the refusal, the reason where known, advice offered, action taken, and whether the GP, prescriber, pharmacist or other professional was contacted.

Where a service user appears unable to understand, retain, weigh or communicate a decision about medication, a decision-specific mental capacity assessment must be completed in accordance with the Mental Capacity Act 2005. Where the service user lacks capacity, any decision must be made in their best interests, using the least restrictive option and involving relevant people as appropriate.

Repeated refusal, refusal of high-risk medication, or refusal that may cause deterioration must be escalated promptly to the GP, prescriber or relevant healthcare professional. Covert administration must only be considered where the legal requirements described in this policy are met.

Medication must not be used as a form of unlawful restraint, punishment, convenience or control. Where medication may have a restrictive effect, the service must consider mental capacity, best interests, deprivation of liberty, safeguarding and restrictive practice requirements.

3.13. Documentation and Record-Keeping

Medication records must be accurate, complete, contemporaneous, legible and securely stored. Staff must record medication support at the time it is provided and must not complete records in advance.

Records may include, where applicable, MAR charts, PRN protocols, PRN outcome records, controlled drug registers, medication receipt records, ordering and re-ordering records, medication reconciliation records, fridge and room temperature records, medication audits, homely remedy records, topical medication administration records, patch charts, body maps, covert medication records, mental capacity assessments, best interests decisions, medication error reports, adverse reaction records, disposal and returns records, and professional advice or correspondence.

MAR charts must clearly show the service user’s name, date of birth or other identifier, allergies, medicine name, strength, dose, route, time, special instructions, start date, stop date where applicable, and staff signatures or electronic audit trail.

Any handwritten entry or amendment to a MAR chart must be checked, signed and dated by two authorised staff wherever possible and verified against written prescriber or pharmacy information. Staff must not rely on verbal instructions unless this is unavoidable and the instruction is recorded, read back, confirmed and followed up in writing.

Medication records must be available for audit, review and inspection. Electronic records must have secure individual staff access and a clear audit trail showing entries and amendments.

3.14. Medication Reviews

Service users must be supported to have their medicines reviewed by the GP, pharmacist, prescriber or appropriate healthcare professional at appropriate intervals and whenever concerns arise.

A medication review must be requested where there are repeated refusals, frequent PRN use, suspected side effects, swallowing difficulties, falls, changes in cognition, changes in behaviour, pain, drowsiness, hospital admission or discharge, end-of-life care needs, medication errors, changes in health, or concerns that a medicine may no longer be required or effective.

Outcomes of medication reviews must be recorded and reflected in the MAR chart, personal plan and risk assessments. Staff must ensure discontinued medicines are removed from current use and returned or disposed of safely.

4. Managing Medication Assistance Efficiently

4.1. Leadership and Accountability

The Registered Manager is responsible for ensuring that this policy is implemented, monitored and reviewed. The Responsible Individual must maintain oversight of the service’s medication systems through governance, audit, incident review and quality assurance arrangements.

The Medication Lead or delegated senior staff member is responsible for supporting day-to-day medication practice, including stock checks, audit, staff guidance, liaison with pharmacy and escalation of concerns.

All staff involved in medication support are personally responsible for working within their training, competence, job role, this policy, the service user’s personal plan and professional guidance. Staff must not administer or support medication where they have not been trained and assessed as competent.

Agency staff must not administer medication unless the Registered Manager or senior person on duty has confirmed that they have appropriate training, competence, authorisation and access to the relevant personal plans, MAR charts and medication procedures.

4.2. Staff Training and Competency

Staff must complete medication training appropriate to their role before administering, managing or supporting service users with medicines. Training must include safe administration, MAR charts, storage, ordering, re-ordering, receipt, reconciliation, controlled drugs, PRN medicines, covert medication, consent and capacity, refusal, errors, adverse reactions, safeguarding, duty of candour, infection prevention, disposal and escalation.

Staff must complete a practical competency assessment before they are authorised to administer or support medication. Competency must be reassessed at least annually and sooner if there is a medication error, near miss, concern about practice, long absence from medication duties, change in role, change in medication system, or introduction of specialist medicines.

Staff undertaking specialist or delegated medicines-related tasks must receive task-specific training from an appropriate healthcare professional and must be assessed as competent before undertaking the task. Delegated tasks must be recorded in the service user’s personal plan and must include clear instructions, limitations and escalation arrangements.

Records of medication training, competency assessments, supervision, refresher training and authorisation must be retained and available for inspection.

4.3. Audit and Continuous Improvement

Medication systems will be audited at least monthly and more frequently where risks, errors, safeguarding concerns, stock discrepancies or changes in practice indicate this is required.

Medication audits must include, where applicable, MAR charts, signatures, omissions, refusal records, PRN protocols and outcomes, controlled drug records and balances, fridge and room temperature records, stock levels, expiry dates, opening dates, ordering and re-ordering, receipt and reconciliation, topical medicines, patches, homely remedies, covert medication records, disposal and returns, medication errors, near misses and evidence of follow-up action.

Audit findings must be recorded, actioned and reviewed. The Registered Manager must ensure that actions are completed within agreed timescales. Repeated themes or significant concerns must be escalated to the Responsible Individual.

Medication incidents, near misses, audit findings, safeguarding concerns, complaints and feedback must be analysed for themes and trends. Learning must be shared with staff through supervision, team meetings, training, competency reassessment and updates to policy or procedure.

Medication audit outcomes and medication-related incidents must inform the service’s quality of care review and continuous improvement arrangements.

5. Related Policies

This policy is supported by:

6. Policy Review

This policy will be reviewed at least annually, or sooner where there are changes in legislation, Welsh Government statutory guidance, CIW requirements, NICE guidance, local Health Board guidance, pharmacy procedures, medication systems, service provision, audit findings, safeguarding concerns, medication incidents or identified learning.

The Registered Manager is responsible for ensuring that changes are communicated to staff and implemented in practice. The Responsible Individual will maintain oversight to ensure that the policy remains up to date and that staff have access to, and understanding of, the current version.

Where changes directly affect service users or their representatives, information will be shared in an appropriate format and in line with the service user’s communication needs.

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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