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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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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 aligns with:

• The Regulation and Inspection of Social Care (Wales) Act 2016, which requires service providers to ensure safe medication practices​.
• The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, which mandate safe handling, storage, and administration of medication​.
• The Social Services and Well-being (Wales) Act 2014, which supports person-centred care, ensuring service users’ rights and dignity.
• The Medicines Act 1968 and The Misuse of Drugs Act 1971, which govern the legal framework for medication use and controlled drugs.
• Care Inspectorate Wales (CIW) guidance, which emphasises safe medication administration and management​.

2. Scope

This policy applies to:

• All staff members, including registered nurses, care workers, and agency staff involved in medication administration.
• Service users, ensuring their medication needs are met safely and in accordance with their care plan.
• Families, carers, and representatives, where they have a role in medication management.
• External professionals, including pharmacists and prescribing doctors.

The policy covers:

• Safe storage, administration, and recording of medication.
• Self-administration and promoting independence where appropriate.
• Handling controlled drugs and specialist medications.
• Managing medication errors and adverse reactions.

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:

• Promotes their independence where possible.
• Respects their rights and dignity, including the right to refuse medication.
• Ensures their safety, with staff intervention when required.

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.

3.2. Safe Medication Storage and Handling

We ensure that all medications are stored and handled correctly to prevent contamination, misuse, or loss. This includes:

• Secure storage in a locked, temperature-controlled cabinet.
• Separate storage for controlled drugs, as per The Misuse of Drugs Act 1971.
• Refrigerated storage, where required, with regular temperature monitoring.
• Safe disposal of expired or unused medication, in line with pharmacy guidelines.

Only authorised and trained staff have access to medication storage.

3.3. 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.

3.4. Supporting Self-Administration

Where safe to do so, service users are encouraged to manage their own medication. This is subject to:

• A risk assessment, ensuring they have the ability to store and take medication safely.
• Regular reviews, ensuring their needs have not changed.
• Staff supervision, where partial support is required.

Service users who self-administer must have secure storage for personal medication in their rooms.

3.5. Handling Controlled Drugs and Specialist Medications

Controlled drugs require additional security and documentation. Staff must:

• Record all controlled drugs in a designated register.
• Have two staff members present for administration and record-keeping.
• Conduct weekly stock checks to monitor use and prevent discrepancies.

For specialist medications, such as injectable drugs or patches, only trained and competent staff administer these medications following a detailed care plan.

3.6. Managing Medication Errors and Adverse Reactions

Despite stringent procedures, medication errors can occur. We manage these by:

• Immediate reporting to the Registered Manager.
• Recording the incident in the medication error log.
• Assessing and monitoring the service user for any adverse effects.
• Informing medical professionals for guidance on corrective action.
• Reviewing the error as part of a learning process to prevent recurrence.

If a service user experiences an adverse drug reaction, emergency medical support is sought immediately.

3.7. Consent, Choice, and Right to Refuse Medication

Service users have the right to refuse medication, provided they have the mental capacity to make informed decisions.

• Staff must document refusals and offer support to encourage adherence where appropriate.
• If medication refusal poses a risk, we consult with the GP or prescribing professional.
• Where a service user lacks capacity, best interest decisions are made in consultation with healthcare professionals and family representatives.

3.8. Documentation and Record-Keeping

We maintain accurate medication records, including:

• Medication Administration Records (MAR) sheets, updated in real time.
• PRN (as-needed) medication logs, ensuring appropriate use.
• Incident reports for errors, refusals, or adverse reactions.
• Audit logs, ensuring compliance with CIW regulations​.

All records are stored securely and in accordance with GDPR requirements.

4. Managing Medication Assistance Efficiently

4.1. Leadership and Accountability

• The Registered Manager is responsible for ensuring compliance with medication policies.
• Senior care staff oversee daily medication administration and support junior staff.
• A designated Medication Lead ensures adherence to best practices and regulatory requirements.

4.2. Staff Training and Competency

• All staff receive training on medication handling during induction.
• Annual refresher training is mandatory to ensure up-to-date knowledge.
• Competency assessments are conducted regularly to confirm safe practice.
• Staff are trained in recognising medication side effects, safe storage, and emergency procedures.

4.3. Audit and Continuous Improvement

• Monthly medication audits check compliance with policies and regulations.
• Quarterly reviews assess incident reports and identify trends.
• Feedback from service users and families is used to improve medication support.
• CIW inspections ensure that our medication management meets the highest standards​.

5. Related Policies

This policy is supported by:

• CHW11 – Safe Care and Treatment Policy
• CHW13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CHW16 – Health and Safety at Work Policy
• CHW18 – Risk Management and Assessment Policy
• CHW24 – Management of Accidents, Incidents, and Near Misses Policy
• CHW27 – Staff Supervision, Training, and Development Policy

6. Policy Review

This policy is reviewed annually, or sooner if there are changes in legislation, CIW guidance, or medication safety protocols. Updates are communicated to all staff, and additional training is provided as necessary.

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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.