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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Medication Management and Administration Policy(LD/A)

1. Introduction

{{org_field_name}} is committed to the safe management and administration of medications for all individuals we support. We recognise that proper medication handling is critical to our clients’ health, safety, and well-being. This policy outlines our commitment to high standards of medication safety, and it provides staff with clear guidelines to prevent errors and ensure clients receive the right medication at the right time in the right way.

{{org_field_name}} is registered with the Care Quality Commission to carry out the regulated activity of {{org_field_regulated_activity}} for {{org_field_service_users_bands}} in their own homes.

This policy is grounded in the legal and regulatory framework for social care in England. We adhere to the Care Act 2014, which emphasises meeting individuals’ care needs (including support with medication) and safeguarding their well-being. We also comply with relevant Care Quality Commission (CQC) regulations and Fundamental Standards (e.g. Regulation 12 on safe care and treatment, Regulation 17 on good governance) that require safe handling of medicines and robust record-keeping​. In addition, our practices follow NICE guidance (such as NICE guideline NG67 on managing medicines for adults receiving social care in the community) to ensure we implement nationally recognised best practices​. By following these laws, regulations, and guidelines, {{org_field_name}} aims to promote the health, dignity, and rights of the people we support in all aspects of medication support.

How this policy meets Regulation 12 (Safe care and treatment) and Regulation 13 (Safeguarding)

This policy sets out the practical systems {{org_field_name}} uses to deliver medicines support safely in people’s homes and to prevent avoidable harm. In line with Regulation 12: Safe care and treatment, we will assess risks, prevent and control risks, and ensure staff are competent and supported to deliver safe medicines support. We do this by:

• Assessing and managing medicines risks for each person (including allergies, swallowing difficulties, cognition, capacity, high-risk medicines and time-critical medicines) and recording controls in the care plan and MAR.
• Ensuring consent/capacity decisions are lawful and recorded (Mental Capacity Act 2005; best-interests decisions where required).
• Using the agreed level of support (self-administration, prompting, supervised self-administration, administration) so that medicines support is proportionate and person-centred.
• Following safe administration procedures (the ‘rights’ of administration, correct documentation, and escalation where there are discrepancies).
• Supporting the safe storage and handling of medicines in the person’s home through discussion with the person, respect for their choices, and an individual risk assessment recorded in the care plan.
• Preventing, responding to and learning from errors/near misses through immediate escalation, Duty of Candour where applicable, incident reporting, and root cause review.
• Governance and continuous improvement, including MAR audits, spot checks, competency sign-off, action plans and monitoring trends.

In line with Regulation 13: Safeguarding service users from abuse and improper treatment, we treat medicines misuse as a safeguarding risk. This includes deliberate withholding, coercion, over-sedation, inappropriate PRN use, falsifying MAR records, theft, or using medicines as punishment or control. Any suspicion of medicines-related abuse or neglect is escalated immediately under our safeguarding procedures and reported externally where required.

We also comply with Regulation 13: Safeguarding service users from abuse and improper treatment. Medication-related harm—including deliberate withholding, over-medication, or misuse as a form of control—constitutes abuse or neglect and will be treated as a safeguarding concern, following {{org_field_name}}’s Safeguarding Adults Policy and local authority procedures.

We do not permit any use of medicines as a form of control or punishment. Any restrictive use is exceptional, lawful, proportionate and recorded; misuse is treated as a Regulation 13 safeguarding concern and escalated under our Safeguarding Policy.

2. Scope and Purpose

Scope:

This Medication Management and Administration Policy applies to all staff members of {{org_field_name}} who are involved in any aspect of medication handling or support. It covers care workers providing direct support in clients’ homes, supervisory staff overseeing medication practices, and any other employees who coordinate, administer, or record medications as part of a person’s care plan. Everyone from care assistants to the registered manager must understand and follow this policy to ensure consistency and safety in medication management.

Purpose:

The purpose of this policy is to ensure that the people we support receive their medications safely and correctly, and that staff have clear procedures to follow. By defining roles, responsibilities, and safe practices, we aim to:

• Prevent medication errors, misuse, or harm.
• Ensure medication safety for the people we support at all times, maintaining their health and well-being.
• Comply with all legal requirements and CQC expectations for managing medicines in domiciliary care.
• Support persons’ independence and preferences regarding medication (for example, enabling self-administration where possible) while providing the necessary help when they cannot manage alone.
• Provide staff with guidance and training so they feel competent and confident in managing and administering medications.

Ultimately, this policy helps protect the people we support and staff by establishing a clear framework for how medications are to be handled in line with regulatory standards and best practices.

Assessing medication needs and planning safe medicines support

Before providing any medicines support, {{org_field_name}} completes an assessment to determine the person’s medicines needs and the safest, least restrictive level of support. This assessment is completed by the Registered Manager (or a delegated competent senior staff member) and is reviewed at care plan reviews and whenever needs change.

The assessment will include:

• a current medicines list (name, strength, dose, route, timing) and confirmation of the supplying pharmacy/GP;
• the person’s consent and any communication needs (Accessible Information Standard);
• mental capacity for medicines decisions (decision-specific) and whether advocacy/IMCA is required;
• risks such as high-risk/time-critical medicines (e.g., anticoagulants, epilepsy medicines, Parkinson’s medicines), swallowing difficulties, allergies, side effects, cognition/memory, and risks of misuse;
• agreement on the level of medicines support (self-admin, prompting, supervised self-admin, administration) and any boundaries;
• home environment risks (safe storage location, access by children/visitors, fridge storage where required, sharps arrangements); and
• how we will escalate concerns, including who to contact for medicines queries and urgent clinical advice.

Outcomes are documented in the care plan and reflected on the MAR. Where information is unclear or incomplete (for example, label/MAR discrepancies), staff will not proceed until clarified with the prescriber/pharmacy/manager.

Medication Support for Autistic People and People with a Learning Disability

The organisation recognises that autistic people and people with a learning disability may have individual communication, sensory, cognitive and emotional support needs which must be considered when assessing, storing, recording and administering medicines.

Before medication support begins, the Registered Manager or a delegated competent senior staff member must ensure that an individual medication assessment identifies:

• The person’s preferred communication methods, including speech, gestures, signing, pictures, Easy Read information and communication aids.
• Their understanding of their medicines and the support they require to take them safely.
• Their ability and preference to manage medicines independently or with support.
• Sensory sensitivities relating to the taste, smell, texture, appearance or administration of medicines.
• Anxiety associated with medication routines, unfamiliar staff, changes to routines or physical contact.
• Preferred medication routines and reasonable adjustments, consistent with prescribed requirements.
• How the person communicates pain, discomfort, adverse effects, distress or refusal.
• Individual medication storage and access arrangements.
• Any relevant Positive Behaviour Support (PBS) plan, communication passport or specialist recommendations.
• Any specific risks associated with medicines, including missed doses, accidental ingestion or difficulties recognising adverse effects.

The findings must be recorded in the person’s care plan, medication risk assessment and medication support instructions. Staff must read and follow these arrangements before providing support.

The assessment must be reviewed when the person’s needs, communication, medication or circumstances change.

Autism or a learning disability must never be treated, by itself, as evidence that a person lacks mental capacity. Capacity must be considered in relation to the specific decision and in accordance with the Mental Capacity Act 2005.

Procedure for Safe Medication Support for Autistic People and People with a Learning Disability

Before supporting a person with their medicines, staff must:

1. Read the person’s current medication support plan, medication risk assessment, communication profile and any relevant Positive Behaviour Support plan.
2. Confirm the person’s identity and check the current medication administration record (MAR), prescription directions, allergies, prescribed dose, route and administration time.
3. Communicate with the person using their preferred method, which may include simple spoken explanations, pictures, Easy Read information, gestures, signing or an individual communication aid.
4. Explain the proposed medication support, allow adequate processing time, offer appropriate choices and seek the person’s consent.
5. Consider individual sensory needs, including sensitivities to taste, texture, smell, touch, noise, lighting and unfamiliar routines.
6. Check that medicines have been stored in accordance with the manufacturer’s instructions and the person’s individual risk assessment. Staff must respect the person’s home, independence and agreed access arrangements.
7. Administer or support medicines only to the level authorised in the care plan and only where the staff member has received appropriate training and demonstrated competence.
8. Record the support provided accurately and contemporaneously on the MAR and any additional records required by the care plan.
9. Observe and report suspected adverse effects, unusual sedation, changes in behaviour, swallowing difficulties, refusal, missed doses or other medication-related concerns.

Where a person declines medication, staff must not use threats, intimidation, force or unauthorised concealment of medicines. Staff must follow the medication refusal procedure, assess urgency, document the refusal and seek appropriate advice from the manager, pharmacist, prescriber or urgent healthcare service as indicated by the risk.

Staff must never crush, alter, mix or conceal medication without the required clinical authorisation and lawful decision-making.

Any discrepancy, suspected medication error or safeguarding concern must be reported promptly in accordance with the organisation’s medication incident and safeguarding procedures.

3. Types of Medication Support Provided

{{org_field_name}} delivers a range of medication support services tailored to each client’s needs, as identified in their care plan. The types of medication support we provide include:

• Prompting/Reminding: Care staff remind the client to take their medication at the appropriate times. This involves verbally prompting or gently reminding the service user to take their medicine. The client retains responsibility for self-administering the dose; the staff’s role is only to remind and ensure the person hasn’t forgotten. (Example: saying, “It’s time to take your blood pressure tablets now,” to a client who then takes the medication themselves.)
• Administering Medication: Trained care staff take full responsibility for administering medication directly to the service user. This means the staff prepares the dose (e.g. taking pills out of a blister pack or measuring a liquid) and gives it to the client by the correct route (such as orally, via a feeding tube, etc.), in accordance with the prescription. The staff member then documents the dose on the MAR chart (Medication Administration Record). Administering medication requires the care worker to follow the exact instructions on the pharmacy label or prescription and adhere to the “5 rights” (right person, right medication, right dose, right time, right route – plus documentation) to ensure accuracy and safety.

• Assisting with Controlled Drugs: In cases where a service user is prescribed a controlled drug, trained and authorised staff may support or administer that medicine in line with the care plan, risk assessment, prescriber’s instructions and current guidance. In domiciliary care, controlled drugs in a person’s own home remain that person’s own medicines. There is no automatic requirement for them to be stored separately, in a locked container, or in a controlled drug cupboard. Any storage arrangement must be based on the person’s wishes and an individual risk assessment.

Staff must administer controlled drugs in the same safe, person-centred way as other medicines, while recognising that some controlled drugs carry a greater risk of misuse, overdose or accidental harm. Where a risk assessment identifies additional concerns, proportionate control measures will be recorded in the care plan. These may include clearer recording arrangements, stock checks where specifically required, or escalation arrangements, but these must not be applied as a blanket rule.

All administrations must be recorded on the MAR chart. Any discrepancy, suspected misuse, missing medicine, or concern about diversion must be reported immediately to the Registered Manager and managed under incident, safeguarding and escalation procedures.

• Anticoagulants: Anticoagulants, such as warfarin, apixaban, rivaroxaban, and others, are high-risk medications that require precise handling due to their potential to cause serious harm if mismanaged. {{org_field_name}} recognises the critical importance of accurate administration, monitoring, and documentation of anticoagulant therapy. All staff involved in supporting individuals prescribed anticoagulants will receive specific training to understand the medication’s effects, signs of bleeding, and interactions with other drugs and foods. MAR charts must clearly indicate dosage and timing, and any dose adjustments provided by healthcare professionals (e.g., after INR testing) must be confirmed in writing and recorded immediately. Staff must never guess or alter doses and must escalate any concerns—such as signs of bruising, nosebleeds, or unusual fatigue—to a manager or healthcare professional without delay. Close liaison with prescribers and pharmacists is maintained to ensure safe management and ongoing review of anticoagulant use.
  
  
• Time-Sensitive Medications: Some medications must be administered at specific times to maintain therapeutic effectiveness or to avoid harm—these include medications for Parkinson’s disease, epilepsy, diabetes (e.g., oral hypoglycemics), and pain relief regimens. At {{org_field_name}}, we identify all time-sensitive medications during the initial assessment and care planning process. These medications are clearly marked on the MAR chart and highlighted in the individual’s care plan. Staff are trained to prioritise punctual administration and understand the clinical importance of timing. Missed or delayed doses of time-sensitive medication must be reported to a manager immediately and recorded as a medication error, triggering an internal review. If a visit is running late due to unforeseen circumstances, staff must contact the office for guidance before administering the medication outside the scheduled window. Our scheduling system aims to ensure that visits align with critical medication timings, and this is monitored through regular audits.
  
  
• Flammable Medication Storage: Some medications used in domiciliary care—such as alcohol-based topical preparations, aerosol sprays, or inhalants—contain flammable substances that pose fire and safety risks if not stored appropriately. {{org_field_name}} ensures that all flammable medications are identified during the care planning and risk assessment process. These items must be stored away from heat sources, direct sunlight, and electrical appliances, and should never be kept near cooking areas or radiators. Where practical, flammable medications should be kept in a designated, well-ventilated, and cool location as agreed with the person we support and their family or representative. Staff are trained to recognise flammable products and to follow manufacturer instructions regarding storage and handling. Additionally, care workers must not smoke or use open flames near these medications and should report any safety concerns immediately. If there is any uncertainty about how a product should be stored, staff must seek guidance from a manager or pharmacist before proceeding.
  
  
• PRN (“As Needed”) Medication: PRN medications are those taken only when required, rather than on a fixed schedule. Our staff will administer PRN medication when the service user needs it, based on the prescriber’s instructions and the care plan. Clear criteria should be documented for when to give a PRN medicine (for example, a painkiller for reported pain, or a laxative if no bowel movement for a certain number of days). Before giving a PRN medicine, staff must confirm that it is needed at that time – for instance, by asking the client if they are in pain or by observing symptoms – and check the timing of the last dose to ensure it’s safe to give another (respecting the minimum interval between doses and the maximum doses per day)​. PRN doses are recorded on the MAR chart with the exact time given, and the reason for giving the medication is noted (e.g. “Paracetamol 500mg given at 2:00 PM for headache”). Staff also later monitor the effect, and if the PRN medication is not effective or if the client’s need for it is increasing, they will report this to a supervisor or the client’s GP for review.
  
  
• Applying Creams, Ointments, or Patches: Care workers apply topical medications (such as creams, ointments, or transdermal patches) as prescribed. This might include applying a prescribed cream to a skin area or placing a patch (like a pain-relief or nicotine patch) on the body. Staff will ensure they understand the instructions – for example, “apply to clean, dry skin on the upper arm daily” or “apply cream to rash on legs twice a day.” They will use gloves and appropriate infection control practices when applying creams to protect both the client and themselves. After application, the staff member documents it on the MAR chart or a topical medication administration record, including what was applied and where (if relevant), especially for patches which may need rotation of application sites. Used patches or any residual cream on gloves will be disposed of safely.
  
  
• Administering via PEG (Percutaneous Endoscopic Gastrostomy) Tube: For clients who receive medication through a PEG tube (a tube directly into the stomach), trained staff can administer medications using this route. This is a specialised task – only staff who have received specific training in PEG feeding/medication administration will perform it. The procedure involves preparing the medication in the appropriate form (liquid or finely dissolved tablets, as per pharmacy instructions), flushing the PEG tube with water before and after giving the medicine to ensure it is clear, and positioning the person properly (usually upright) to prevent complications. Staff must follow infection control procedures (e.g. hand hygiene, wearing gloves) and ensure the PEG tube is handled gently and correctly. After administering, they will confirm the medication has been given and record it on the MAR chart. Any issues with the PEG (such as blockages or site inflammation) are reported immediately. We do not administer enteral feeds or medication via PEG unless specifically trained and the task is in the care plan, and we always coordinate with healthcare professionals for guidance on PEG care.
  
  
• Specialist Tasks Not Provided: Certain medical tasks fall outside the scope of what {{org_field_name}} care staff will do. Specifically, insulin administration (insulin injections) for diabetic clients is not performed by our domiciliary care staff – these injections are carried out by district nurses or other qualified healthcare professionals. This is due to the high-risk nature of insulin and the need for clinical judgment in adjusting doses. Likewise, any other injections (such as intra-muscular or sub-cutaneous injections), controlled oxygen therapy, or invasive procedures are generally not undertaken by our care workers unless a specific agreement and training are in place (with appropriate delegation by a healthcare professional). If a service user requires such interventions, arrangements will be made with community nursing services. Our staff’s role may be to observe and report concerns in these cases, but not to perform the injection or specialised task itself. This limitation is in place to protect service users and staff, ensuring that only competent healthcare professionals handle certain high-risk medications.

Levels of Medicines Assistance – Definitions and Procedures

This section explains exactly what support {{org_field_trading_name}} provides at each level, when the level is appropriate, what staff must do, and what sits outside our remit. The agreed level is always recorded in the care plan and on the MAR (Medication Administration Record), with any limits or special instructions.

Level 0 — Self-Administration (Independent)

Most people prefer to remain in control of their medicines. Where a person can store, select, and take their own medicines safely, staff do not handle medicines.
Staff may still:

• check the environment is safe (lighting, water available),
• observe from a respectful distance if requested,
• record “Self-administered” on the MAR if the commissioner requires an audit trail.

When used: person has capacity (or best-interests decision supports independence), can identify their medicines, understands timing/dose, and risks are low.

Staff must not: set up pill organisers, decant/blister-pack medicines, or alter dosage forms.

Level 1 — Prompts and Reminders (Verbal/Environmental Support)

Staff give timely prompts (in person or agreed tele-prompt), read labels aloud, and provide simple practical help without selecting the medicine or presenting it to the person. Staff may open outer packaging or a difficult bottle if the person then takes the dose themselves.

When used: person knows what to take but benefits from cueing due to memory, vision, language, or dexterity barriers.

Documentation: MAR entry as “Prompted/Reminded”; note any refusal or delay.

Boundaries: no pouring, no placing tablets into a pot for the person, no deciding which medicine is due.

Level 1+ — Supervised Self-Administration

The person selects and takes their medicine; staff witness to confirm the correct medicine and dose were taken at the correct time. This is used where proof of adherence is required or risks are slightly higher.

When used: new high-risk medicine (e.g., anticoagulant), early post-discharge, safeguarding concerns about adherence.

Documentation: MAR signed as “Supervised self-admin”; record variances.

Level 2 — Administration by Trained Staff

Staff select the correct medicine for the correct person, prepare it, and administer it (e.g., present tablets in a pot, administer liquids via oral syringe, give eye/ear/nasal drops, apply topical creams, fit transdermal patches, support inhaler technique, or give oxygen as prescribed). Staff confirm the dose has been taken/absorbed and record it immediately.

Pre-conditions: documented consent (or best-interests decision), risk assessment, and a current MAR produced by the supplying pharmacy/GP. Staff must be trained, observed as competent, and listed on the medicines competency matrix.

Controls:

Time-critical medicines (e.g., Parkinson’s, anticonvulsants, insulin if in scope): visits are scheduled to meet the clinically safe window noted on the MAR/care plan.

Transdermal patches: use a body map, rotate sites, date/time on patch backing if manufacturer permits, and document removal/application.

Topicals/creams: use a body map and apply only to specified sites.

Inhalers/nebulisers: check device technique, spacer use, and cleaning per manufacturer instructions.

Oxygen (if prescribed in care plan): follow flow-rate, fire-safety rules, and supplier guidance.

Not permitted at Level 2: crushing tablets or opening capsules, altering dosage forms, or any covert administration unless authorised (see Level 3).

Level 2C — Controlled Drugs (CDs) in the Person’s Home

Where a CD is administered by staff, a second check is undertaken whenever possible (two staff), or a single-worker double-check using a defined checklist and photo-MAR where lone working is unavoidable. Running balances are reconciled on the MAR each visit if required by the commissioner/care plan.

Storage: CDs remain in the person’s home; staff encourage safe storage but do not remove personal medicines.

Level 2PRN — “When Required” Medicines

PRN medicines are used only in line with a written PRN protocol that states the indication, maximum dose/24h, minimum interval, non-drug alternatives, when to escalate to 111/999/GP, and what to record (effect within agreed review time, e.g., 30–60 minutes).

Examples: analgesics, anxiolytics, bronchodilator inhalers, bowel medicines.

Level 3 — Specialist/Complex Tasks (Only If Specifically Commissioned)

Certain tasks are outside routine practice and are undertaken only where the care plan explicitly commissions them and staff have role-specific training, assessment, and ongoing competency sign-off. Examples may include:

PEG/enteral administration of medicines (with pharmacy compatibility guidance and flush protocols),

insulin administration or dose adjustment under a written delegation from the community nursing team, buccal midazolam for seizures under an emergency plan.

If {{org_field_trading_name}} does not offer a specific task, the care plan must name the responsible clinician/service (e.g., community nursing).

Covert Administration (Exception Process)

Medicines must not be hidden in food/drink unless a lawful covert pathway is followed: capacity assessment for the decision; best-interests meeting with a pharmacist/GP; product-specific advice on crushing/sprinkling; clear documentation on the MAR/care plan; and frequent review to seek less-restrictive alternatives.

Changes in Level / Escalation

If staff believe the current level is no longer safe or proportionate (missed doses, repeated refusals, swallowing difficulties, delirium, safeguarding concerns), they pause non-urgent administration, keep the person safe, record the issue, and notify the coordinator/Registered Manager. The care plan, risk assessment, and visit schedule are reviewed the same day, and prescriber/pharmacy are contacted where needed.

Refusals, Omissions, and Errors

Refusal: respect the decision, explore reasons, re-offer once if appropriate, record precisely (“refused – stated nauseous”), and inform as per care plan.

Omission: document reason (e.g., “medicine unavailable”), arrange urgent supply if needed, and escalate for time-critical medicines.

Error/near miss: treat as an incident; inform the person/representative, prescriber/pharmacy if clinically indicated, and follow the incident and duty-of-candour procedure.

Training, Competency, and Supervision

Only staff who have completed medicines training (including time-critical, CDs, PRN protocols, body-maps, and error reporting), been observed in practice, and are recorded as competent may work at Level 2/2C/2PRN/3. Competency is re-assessed at least annually, or sooner after an incident, with spot checks and MAR audits by the senior team.

Reasonable Adjustments and Communication

We follow the Accessible Information Standard: needs are asked-about, recorded, flagged, shared, and met. Adjustments may include large-print/easy-read MARs, pictograms, translation/interpreter support, and longer visits for safe administration.

Person-Centred Medication Administration for Autistic People and People with a Learning Disability

Staff must adapt medication support to the person’s assessed needs, communication preferences, sensory sensitivities and level of independence.

When supporting a person with medicines, staff must:

1. Approach the person calmly and use their preferred communication method.
2. Explain which medicine is being offered, its purpose and what will happen next, using accessible language or communication aids.
3. Allow sufficient time for the person to process information, ask questions and make decisions.
4. Avoid rushing, repeated demands, unnecessary physical contact or approaches known to cause distress.
5. Offer appropriate choices, such as a preferred location, a familiar staff member or water with medication, where clinically suitable.
6. Maintain familiar routines wherever possible while following prescribed administration instructions.
7. Observe for non-verbal signs of discomfort, anxiety, pain, sensory overload or medication side effects.
8. Seek valid consent and follow the Mental Capacity Act 2005 where capacity is in question.
9. Respect refusal, establish the possible reason and follow the medication refusal and escalation procedures.
10. Record administration, refusal, omission or delay accurately on the Medication Administration Record (MAR).

Where a person experiences difficulty swallowing medicines or sensory difficulties with a formulation, staff must seek advice from the prescriber or pharmacist about appropriate alternatives.

Staff must not crush tablets, open capsules, mix medication into food or change formulations without appropriate professional authorisation. Concealed administration must not take place unless a lawful, individually documented covert-medication process has been followed.

If the person becomes distressed during administration, staff must pause non-urgent medication support, seek to understand the cause and use the person’s agreed communication and Positive Behaviour Support strategies.

For time-critical medication, staff must seek prompt clinical advice if a dose cannot be administered safely or is refused.

Medication must never be forced, used as punishment or administered through threats or inappropriate pressure.

Tasks We Do Not Undertake (Unless Explicitly Commissioned and Competent)

Re-dispensing/decanting medicines; transcribing directions; altering dosage forms without prescriber/pharmacist approval; using another person’s medicines; administering out-of-date or unlabelled medicines; making clinical dosing decisions; or any invasive/specialist procedures not named in the care plan.

4. Staff Responsibilities and Training

Safe medication management is a key responsibility for our staff. {{org_field_name}} ensures that any staff member involved in medication tasks is properly trained, assessed as competent, and fully aware of their duties. The following are the expectations and requirements for staff regarding medication responsibilities and training:

• Training Before Administration: Only staff who have completed appropriate medication training and have been deemed competent are allowed to administer or assist with medications. New care staff must undergo medication management training as part of their induction (or provide evidence of equivalent training) and be observed by a competent senior staff member when they first administer medication. They must demonstrate understanding of correct procedures (including the 5 or 6 Rights of medication administration) before they can work unsupervised with medications.
• Annual Refreshers and Competency Checks: All care staff must renew their medication training at least once a year and have their competency re-assessed regularly​. {{org_field_name}} provides annual refresher training that updates staff on any changes in best practices, company policy, or guidelines. In addition, a manager or qualified trainer will conduct periodic competency evaluations, which include direct observation of the staff administering medicines and a review of their knowledge (for example, checking they know how to read a MAR chart correctly, what to do if a dose is missed, etc.)​. If a staff member’s competency has lapsed or if an error has occurred, they will not be allowed to administer medication until they receive re-training and are re-assessed as competent. Keeping knowledge and skills up-to-date on an ongoing basis is essential for maintaining safety.
• Following the Policy and Procedures: Staff members are expected to follow this Medication Management Policy and all related procedures precisely. They must always adhere to the “Five Rights” (Right patient, Right medication, Right dose, Right time, Right route) plus ensure proper documentation for each administration – sometimes called the 6th right​. Before giving any medicine, the care worker should verify these details: confirm the client’s identity, double-check the medication name and strength against the MAR chart and prescription label, measure the correct dose, give it at the correct time, and use the correct method (e.g., by mouth, via PEG, applied to skin, etc.). After administering, they must immediately record it. If at any point something doesn’t match (for example, the MAR chart doesn’t match the pharmacy label, or the client says they already took the dose), the care worker must not proceed until the discrepancy is resolved. Staff should also check expiry dates on medicines and never give a medication that looks compromised (such as tablets that are discoloured or a cream that has separated) – instead, they should consult a supervisor or pharmacist for advice.
• Communication and Consent: Staff should obtain consent from the person we support before administering medication whenever the person is able to give it. This might be as simple as asking “Shall we take your morning pills now?” and ensuring the person is willing. If a person we support refuses a medication, the staff must respect that decision (provided the person has capacity to make that choice) and follow procedures for refusal (e.g., try again a short while later, and if still refused, record the refusal and inform the supervisor/office). Under no circumstances should staff force or trick someone into taking medication. If a client lacks capacity to consent and medication is given in their best interest (in line with the Mental Capacity Act), this will be detailed in their care plan and might involve covert administration only under proper authorisation and guidance. In all cases, respectful communication and the service user’s dignity are paramount.
• Accountability and Reporting: Staff have a duty to report any concerns or issues related to medication immediately. This includes reporting any errors (as detailed in Section 7 below), near-misses, or if they notice any changes in a client’s condition that might be related to medication (for example, side effects or if the client appears to be over-medicated or not taking their meds off-schedule). They should also inform their supervisor if they feel unsure about administering a certain medicine or if they haven’t been trained for a specific task (e.g., a new type of inhaler or eyedrops technique). No staff member should perform a medication task they are uncomfortable with or untrained for – asking for guidance is always encouraged over risking a mistake. Management will support staff in clarifying instructions (by liaising with pharmacists or doctors as needed) and will provide additional training or mentoring if a staff member needs more confidence with medications.
• Ongoing Professional Development: Medication management is included in our ongoing staff development. Team meetings and supervision sessions will regularly cover medication topics – such as discussing any incidents that occurred (in a blame-free, learning-focused manner), updates in policy, or sharing tips for safe practice. Staff are encouraged to share feedback and suggestions for improvement. For instance, if a staff member finds a better way to document PRN reasons or a common challenge in the field, they should bring it up so the whole team can learn. By fostering continuous learning, {{org_field_name}} ensures that our medication practices remain current and effective. We keep records of all training and competency assessments for each staff member as part of our compliance and quality assurance.
• Delegated healthcare tasks
  Where an NHS professional delegates a task related to medicines (for example, administering via PEG, inhaler spacer technique, or transdermal patch rotation), we will only accept delegation when written task-specific instructions and risk assessment are in place; named staff have been trained and assessed as competent by an appropriate clinician; ongoing supervision/reassessment is defined; and escalation/withholding criteria are documented in the care plan and MAR. The Registered Manager retains oversight and may decline delegation if safe governance cannot be assured.
• Medication concerns: who to contact (24/7)

Urgent clinical risk (e.g., overdose taken, chest pain, anaphylaxis, seizures, suspected sepsis): Call 999 immediately.

Time-critical doses missed (e.g., Parkinson’s/anticonvulsants/insulin if in scope) or serious side-effects: Contact the Registered Manager/on-call on {{org_field_out_of_hours}} at once; we may also call the person’s GP or NHS 111 for clinical advice.

Supply problems (no stock/late delivery, label discrepancies): Inform the office/Registered Manager on {{org_field_out_of_hours}} ; we will liaise with the GP/pharmacy to prevent missed doses.

Safeguarding/abuse concerns (e.g., deliberate withholding, over-medication): Escalate per Safeguarding Adults Policy and inform the local authority; record and notify CQC where required.

All actions and advice received must be documented on the MAR and in daily notes (include names, times and instructions).

Additional Staff Training: Learning Disability, Autism and STOMP

Staff supporting autistic people and people with a learning disability must receive appropriate training and guidance on:

• Understanding individual communication needs and making reasonable adjustments.
• Recognising sensory sensitivities, distress, emotional reactions and communication through behaviour.
• Supporting informed decisions and applying the Mental Capacity Act 2005.
• Person-centred medication administration, storage and recording.
• Positive Behaviour Support and identifying unmet needs.
• STOMP principles and the prevention of inappropriate psychotropic medication use.
• Recognising medication side effects, including excessive sedation.
• Safe use, monitoring and recording of prescribed PRN medicines.
• Recognising and escalating concerns about inappropriate medication use or chemical restraint.

The Registered Manager must ensure staff understand the individual’s care plan, medication risk assessment, communication guidance and relevant Positive Behaviour Support plan.

Staff must be assessed as competent before undertaking medication administration and must receive additional guidance when supporting a person with complex medication or communication needs.

Training, competency assessments, supervision and refresher activities must be documented.

5. Medication Recording and Audits

Accurate documentation is a fundamental part of safe medication administration. Every interaction with a person’s medication must be recorded properly. In addition, regular audits of these records are conducted to verify that our medication management is safe, effective, and compliant with standards. Below are our procedures for recording and auditing:

• Use of MAR Charts: We use Medication Administration Record (MAR) charts for each service user who receives any level of medication support (prompting, assistance, or full administration). The MAR chart is the official log of all medications given. Staff must make an entry on the MAR chart every time they prompt or administer a medication, including the date, time, and their initials or signature. If a medication was supposed to be given but was not (e.g., the client refused, or the medication was temporarily not available), the staff should still document the occurrence by using the designated code or symbol on the MAR (and explaining on the back of the chart or appropriate section why it wasn’t taken). For example, a common practice is to circle the scheduled time and write a code for refusal (“R”) or for other reasons like “N” (not given) with a note. It is vital that MAR charts have no blanks for scheduled doses – every scheduled dose must be accounted for with either a confirmation of administration or a reason why it was omitted. Clear, legible handwriting is required, and entries should never be altered with correction fluid; if a mistake is made, it should be crossed through with a single line and initialled. Remember: if it’s not documented, in the eyes of regulators it didn’t happen. Poor record-keeping can put both the service user and the care worker at risk, leading to dosing errors or missed doses​. Therefore, maintaining up-to-date and precise MAR records is a strict requirement.
• Additional Recording Tools: Besides MAR charts, staff may encounter other recording tools depending on the situation. For example, there might be a Controlled Drug register/log kept in the client’s home (if we are tracking quantities of controlled drugs), or a topical cream chart for recording applications of creams and patches separately. Staff should ensure they understand and use all required documentation correctly. When in doubt, they should ask a supervisor. All documents related to medication are considered part of the care record and must be treated with the same accuracy and confidentiality as other records. We also record any advice or instructions given by healthcare professionals (like a GP or pharmacist) regarding medications in the daily communication notes or a medical visit form, and update the care plan/MAR accordingly. Keeping thorough records ensures continuity of care especially if multiple staff support the same client – each staff can see what was done or given previously and when.
• Monthly Medication Audits: {{org_field_name}} conducts monthly audits of medication administration records. Typically, at the end of each month (or at a set schedule), a designated senior staff member or manager will collect or review the MAR charts and related medication records for each service user. During an audit, we check for completeness (no missing signatures/initials, every dose accounted for), legibility, and correctness of entries. We verify that any gaps or anomalies have appropriate explanations, and that PRN usage is recorded with reasons. We also reconcile the number of doses administered with the remaining stock for certain medications when feasible – especially important for controlled drugs or for monitored dosage systems (like blister packs) to ensure no doses are unaccounted for. These audits are documented, and any issues or errors identified are followed up immediately with the staff team. For instance, if an audit finds that a MAR chart has a missed signature, we would investigate to find out if the dose was actually given and just not signed for (a documentation error) or if it was potentially missed (an administration error), and take appropriate action. Regular auditing is part of our governance process to catch problems early and maintain high standards​. It also helps us identify if additional training or support is needed for staff in certain areas of medication management.
• Audit Feedback and Action: After each audit, the findings are shared with the care team and management. Positive findings (e.g., excellent documentation practices) are acknowledged, and any negative findings are addressed constructively. If systemic issues are found (such as many staff forgetting to record the reason for PRN meds), we will update our training and reminders to all staff. If individual issues are found, the manager will speak to the staff member concerned to provide guidance or additional training. The audit process is also an opportunity to update our policies: for example, if audits reveal that the MAR chart format is confusing staff, we might redesign the form or provide clearer instructions.
• Accountability: The Registered Manager {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}} is responsible for ensuring these audits happen and that action is taken on the results. Audit records are kept as evidence of our ongoing quality monitoring, which can be provided to CQC inspectors or commissioners to demonstrate our compliance with medication management standards.
• External Audits: In some cases, we may also engage with local pharmacists, consultancy companies or commissioners for additional audits or medication reviews. Pharmacists might perform an annual medication review for clients (checking that all medications are still needed and being used correctly) or review our MAR charts and storage as part of a service improvement. We welcome such external input, as it provides an objective check and expert recommendations. Any feedback from external audits or reviews is incorporated into our practice. We also ensure that the medication aspect of each person’s care plan is reviewed regularly (at care plan reviews or if their health changes), to confirm that the level of support we provide is still appropriate (for example, someone initially needed administration but can now self-manage with prompting, or vice versa).

Additional Medication Recording Requirements for Autistic People and People with a Learning Disability

In addition to standard MAR requirements, staff must document relevant information about the person’s individual medication support needs.

Records must include, where applicable:

• Communication methods and reasonable adjustments used during medication support.
• The person’s expressed wishes, choices, consent or refusal.
• Any medication omission or delay and the reasons identified.
• Signs of distress, anxiety, sensory discomfort or pain associated with medication.
• Actions taken to understand and respond to the person’s communication or unmet needs.
• Non-medication interventions used before considering PRN medication, where appropriate.
• The prescribed indication, dose, time and reason for PRN administration.
• The person’s response to PRN medication, including effectiveness and adverse effects.
• Changes in wellbeing, behaviour, alertness or physical health that may indicate medication side effects.
• Advice received from the prescriber, pharmacist, Registered Manager or other professionals.

When a person communicates without speech, staff must record observable signs, such as gestures, facial expressions, movements or vocalisations, and distinguish these observations from staff interpretations.

Records must be factual, respectful, contemporaneous and sufficiently detailed to support continuity of care.

Medication records and associated care notes must be reviewed where recurring distress, refusals, side effects or increased PRN medication use are identified.

6. Storage and Disposal of Medication

Proper storage and disposal of medications are essential to prevent misuse, deterioration, or accidental ingestion. In domiciliary care, medications are kept in the person’s home, so we work collaboratively with clients (and their families where appropriate) to manage this safely. This section details how staff should handle medication storage in clients’ homes and what to do with unused or expired medications, including specific guidance for controlled drugs.

• Storage in the Person’s Own Home: In domiciliary care, medicines are usually stored in the person’s own home and remain their property. {{org_field_name}} will discuss and agree with the person, and where appropriate their family, representative or advocate, how medicines are kept so that arrangements are practical, person-centred and as safe as possible. The agreed arrangements will be recorded in the care plan and reviewed whenever needs, risks or circumstances change.

Medicines should be stored in a way that follows the manufacturer’s instructions and helps maintain their safety and effectiveness. This includes considering temperature, moisture, direct sunlight, refrigeration where required, and avoiding unsuitable storage locations. Staff should check for obvious concerns such as damaged packaging, expired medicines, signs of damp, heat exposure, or a fridge that is not working properly.

There is no blanket requirement for medicines in a person’s own home to be locked away or kept in secure storage. Storage arrangements must reflect the person’s wishes unless a risk assessment identifies a reason to agree a different arrangement. Risk assessments should consider, for example, access by children, confusion or memory difficulties, accidental ingestion, risks of misuse, safeguarding concerns, and any medicines that require refrigeration or special handling.

Where risks are identified, staff will discuss safer storage options with the person and record the agreed arrangements in the care plan. This may include, where appropriate, keeping medicines in a consistent place, storing them out of reach of children, using a clearly labelled container, or separating medicines that require refrigeration. Any additional precautions must be proportionate and must not unnecessarily restrict the person’s choice or control in their own home.

• Individualised Medication Storage for Autistic People and People with a Learning Disability

Medication storage arrangements must reflect the person’s individual abilities, communication needs, sensory preferences, wishes and assessed risks.

Staff must consider:

• Whether the person can safely access and manage their own medicines.
• Whether a familiar, consistent storage location supports independence and reduces anxiety.
• Whether accessible labels, pictures or other visual aids would help the person identify medicines.
• Whether the person requires support to distinguish medicines or understand their administration schedule.
• Whether there is an assessed risk of accidental ingestion, medication confusion, misuse or access by other people.
• Whether sensory sensitivities affect the person’s ability to access or handle medicines.
• Whether prescribed storage temperatures, original packaging and other manufacturer requirements are being maintained.

Medication must not automatically be locked away or access restricted solely because a person is autistic or has a learning disability.

Any restriction must be individually assessed, necessary, proportionate, lawful and recorded in the care plan and medication risk assessment.

The person’s medication support plan must specify:

• Where medicines are stored.
• Who is responsible for accessing and securing medicines.
• What support the person requires to manage their medicines.
• Any agreed visual or communication aids.
• What staff must do if medicines are missing, damaged, incorrectly stored or unavailable.

Storage arrangements must be reviewed when the person’s abilities, medicines, risks or circumstances change.

In domiciliary care, staff must follow the agreed arrangements for the person’s home and must not impose restrictions outside their authorised responsibilities.

• Home storage agreement (domiciliary care)
  For people who self-administer or share storage space at home, we agree and document safe storage arrangements (for example, a lockable box, refrigerator segregation, and secure storage of controlled stationery). This is recorded in the care plan and reviewed at each visit block.

• Controlled Drugs in the Person’s Own Home: Controlled drugs in a person’s own home are managed as that person’s own medicines. There is no general legal requirement for a controlled drug cupboard, separate controlled drug register, or special secure storage in a person’s home. Any additional precautions must be based on an individual risk assessment and clearly documented in the care plan.

Staff should remain alert to any signs of discrepancy, misuse, missing medicines or possible diversion and must report concerns immediately. Where a specific commissioner requirement, safeguarding concern or assessed risk justifies additional checks, this must be clearly recorded and followed, but such checks must not be treated as a routine requirement for all people receiving domiciliary care.

• Medication Disposal (Expired or Discontinued Medication): Medications that are no longer needed, have expired, or have been discontinued by the prescriber must be disposed of safely. It is dangerous to keep old or unused medications in the home because they could be taken by mistake or misused. Our procedure is that unused medications should be returned to a pharmacy for safe disposal (pharmacies will destroy medications in accordance with regulations). Typically, the service user or their family is responsible for disposal of their medicines; however, care staff should assist in facilitating this if the client cannot do it themselves​. For example, with the client’s permission, a care worker may take the expired medication to the client’s regular community pharmacy. When doing so, staff must document what was removed (name of drug, strength, quantity, date of return) and get a receipt or signature from the pharmacy if possible. This information (date of disposal, what and how much was disposed, and which pharmacy or method) should be recorded in the care notes or on a medication disposal form​. If family members handle the disposal, staff should note in the records which family member took responsibility and when. Important: Staff must never dispose of medications by throwing them in the bin, sink, or toilet. Flushing medications or tossing them in household trash can create safety hazards (risk of someone else finding and ingesting them, or environmental contamination). Always follow proper return-to-pharmacy procedures or local authority guidelines for medication disposal.

• Disposal of Controlled Drugs: Controlled drugs require witnessed disposal. If a controlled drug is discontinued or expired, two authorised people should ideally witness and document the removal of the drug for disposal. In a home care scenario, this could be the care worker and a pharmacist (when returned to pharmacy) or the care worker and a family member who’s an adult. We prefer returning controlled drugs to a pharmacist, who will then destroy it (often requiring a witness pharmacist). Staff must record the handover (e.g., “Returned 5 tablets of morphine 10mg to [Pharmacy Name] on [Date], received by [Pharmacist Name]”).

If a controlled drug needs to be destroyed on site (rare in domiciliary care), a pharmacist or authorised person should come to do it – care staff should not themselves destroy controlled drugs by e.g. crushing and disposing, except under professional guidance. Until disposal, controlled drugs that are no longer in use should be kept in the agreed location identified in the care plan, with any additional precautions based on the individual risk assessment.

 Any used patches (for example, fentanyl patches after use) should be folded so the adhesive sides stick together (to prevent drug leakage) and disposed of in a safe manner (ideally returned to pharmacy or placed in a sharps bin if one is used for that patient).

• Sharps Disposal: Although our staff do not administer insulin or other injections, there may be scenarios where sharps (needles, lancets, syringes) are used in the client’s home – for example, the client might self-inject insulin or a district nurse might administer an injection during a visit, leaving used sharps. We ensure there is a proper sharps container in the home if needed. Care staff should never handle used sharps with bare hands. If assisting with something like an insulin pen needle (only in a prompting role, since we don’t inject), staff must ensure the needle goes straight into a sharps box after use. Do not recap needles. Sharps bins should be collected/replaced by the district nursing service or local council’s clinical waste service when full or when the treatment is completed. Staff should inform the manager if they notice a sharps bin is nearly full or if one is needed and not present.

• Refusals and safe disposal
  If a person refuses medication, staff will not force or repeat dosing. The refusal and reason are recorded on the MAR and care plan, and advice sought per the escalation pathway. Unwanted or expired medicines are not disposed of in domestic waste; we arrange return to the supplying pharmacy (or the person’s agreed disposal service) and keep a disposal record countersigned by a witness.

In summary, the storage and disposal procedures aim to ensure that medications remain effective (through proper storage conditions), are kept out of reach of those who might be harmed by them, and are disposed of in a manner that is safe, traceable, and environmentally responsible. By following these guidelines, we protect our service users and others from the risks associated with improper handling of medications when not in use.

7. Reporting Medication Errors

{{org_field_name}} fosters an open culture where staff are encouraged to report errors or near-misses immediately. A medication error is any deviation from the prescribed medication regimen or the proper procedures – for example, giving the wrong medicine or dose, missing a dose, giving it at the wrong time, or giving it to the wrong person, as well as documentation mistakes that could lead to error. We recognise that even with careful practices, errors can occur, and it is our responsibility to handle them transparently and learn from them. This section describes what staff must do if a medication error or near-miss happens, and how we manage such incidents:

Medication concern—who to contact (in order):

• Registered Manager / On-call: {{org_field_registered_manager_phone}}  (immediately)
• Prescriber/GP (or specialist team named on MAR) for clinical advice
• Pharmacist (supplying pharmacy) for interactions/formulation queries
• NHS 111 for urgent advice; 999 in an emergency
Record actions and advice on the MAR and incident form; inform family/advocate as appropriate.

In depth procedure:

If a medication error or near-miss occurs, staff should take the following steps immediately:

1. Ensure the Person’s Safety First: The first priority is the wellbeing of the person we support. As soon as an error is realised, the care worker should assess the person we support for any adverse effects. If the wrong medication or dose was given, or a dose was missed, monitor the individual for any signs of distress or reactions. Depending on the situation, the staff may need to seek medical advice right away – for instance, by calling the GP, NHS 111, or in severe cases 999 for emergency help. Examples: If a double dose was accidentally given, call a healthcare professional for advice on any symptoms to watch and whether the person needs urgent treatment. If a critical medication (e.g., an anticonvulsant) was missed, the GP might need to advise on whether to take it late or skip it. Staff should not leave the person alone if there are any immediate health concerns; stay until it’s clear how the situation will be managed medically.

2. Report Immediately to Management: As soon as the immediate safety steps are underway, the staff member must inform a supervisor or manager about the error. This should be done immediately (within minutes) once the situation with the client is stabilised. During office hours, the care worker should call the Registered Manager at the office: {{org_field_phone_no}}. If the error happens out of hours, the on-call manager/supervisor must be contacted by phone: {{org_field_out_of_hours}}. (All staff have been provided with the on-call contact number – use the emergency on-call system as per our protocol. Even if it the same company number the on call person will answer the call). It is important to use these established reporting lines so that management is alerted and can assist in managing the aftermath. We use an internal incident reporting system; the staff member should communicate the facts of what happened to the manager (e.g. “I gave Mrs. X the wrong medication at 9am” or “I found that I forgot to give Mr. Y his 8am dose”). Prompt reporting allows the management to give immediate guidance, help decide on contacting medical services (if not already done), and start the documentation process. Note: Staff should use any provided shortcodes or reference codes when documenting or communicating the incident internally if our system requires (for example, using a client ID instead of full name in text messages to maintain confidentiality).

3. Do Not Attempt to Hide the Error – Duty of Candour: Honesty is imperative. The staff member should not try to cover up or rectify the error secretly (for instance, never give a double dose later to make up for a missed dose – this can be extremely dangerous). {{org_field_name}} follows the NHS and CQC’s Duty of Candour, which is a legal obligation to be open and transparent when things go wrong. This means we will inform the service user (and/or their next-of-kin/representative, if appropriate) about the error as soon as possible, explain what happened in a straightforward way, describe what will be done to address it, and apologise for the mistake​. Typically, the manager or senior staff will take responsibility for this communication, but the care worker may be involved or asked to be present during the explanation and apology. We understand that admitting an error can be difficult, but it is essential for maintaining trust and ethical standards. The Duty of Candour applies to all levels of harm – even if no obvious harm occurred, we still acknowledge the error to the client. Management will ensure the conversation with the client/family is documented (and if it meets the threshold of a formal notifiable safety incident under Regulation 20, we will follow those specific steps, such as providing a written follow-up of the apology and investigation outcome).

4. Document the Incident: The error must be documented in detail, both in the client’s records and in the company’s incident log. On the MAR chart, the staff should make a note (according to our MAR policy) about what happened. For example, if a dose was given at the wrong time, record the time it was actually given and circle the scheduled time with a note “given at 10am in error, reported to manager” or if a dose was missed, circle it and write “omitted in error” or similar. The staff member (with manager’s help if needed) must also complete an Incident Report Form as soon as possible, ideally immediately after ensuring the client is safe. The incident report should include: date and time of the error, the names of those involved (client and staff), exactly what the error was, how it happened (if known at that point), what actions were taken (who was notified, what medical advice was sought, client’s status), and any immediate outcome. This report should be factual and clear – it’s fine to note any early thoughts on causes (e.g. “noticed two similar bottles next to each other, may have grabbed the wrong one”) but avoid speculation. This documentation is crucial for later investigation and for regulatory compliance.

5. Management Investigation and Follow-Up: Management will investigate every medication error or near-miss to understand why it happened and how to prevent it in the future. The Registered Manager or a designated investigator will speak to the staff involved and any witnesses individually, review the MAR charts and incident form, and look at the circumstances (for example, were they rushed due to low staffing, was the MAR chart confusing, was the label hard to read, etc.). The goal is to perform a root cause analysis – identifying whether the error was due to human mistake, system issues, communication problems, or other factors. {{org_field_name}} promotes a “fair blame” or “no blame” culture​, meaning the purpose of the investigation is not to punish staff for mistakes made in good faith, but to learn and improve. However, if an investigation were to find wilful negligence, misconduct, or repeated violations of procedure, then disciplinary action could be considered in line with our HR policies. In all cases, the findings of the investigation are documented. We then create an action plan to address any issues found: this could include measures like refresher training for the staff member or entire team, changes to the medication procedures, additional supervision for a period, or adjustments in the care plan (for example, if a client has a very complex regimen, maybe arranging for pharmacy to provide a blister pack). The emphasis is on learning from the error so it does not happen again​. Lessons learned might be shared in anonymised form with the care team (e.g., “We had an incident where a medication was given at the wrong time because the MAR times were unclear; as a result, we have updated how we write MAR charts.”).

6. Reporting to External Authorities: Certain medication errors may need to be reported to external bodies. We follow CQC and local authority guidelines on this. For instance, not all medication errors are required to be notified to CQC – generally, CQC must be notified if the error led to serious outcomes such as death, serious harm/injury, or if it is considered a safeguarding issue (abuse or neglect) or involves the police​. If a medication error causes a death or serious injury, we will inform CQC via the statutory notification process and the local Safeguarding Adults team, as well as RIDDOR if applicable.

Safeguarding Adult Team: {{org_field_local_authority_authority_name}}

Email: {{org_field_local_authority_authority_email}}

Working Tel: {{org_field_local_authority_phone_number}}

Out of Hours Tel:  {{org_field_local_authority_out_of_hours_phone_number}}

Safeguarding Adult Team contact or online referral form: {{org_field_local_authority_information_link}}

If we suspect the error amounts to abuse (for example, a staff member intentionally withholding medication or giving an overdose on purpose), it will be treated as a safeguarding matter and reported to the safeguarding authorities immediately. We also inform the service user’s GP (and other health professionals involved) about the error, especially if medical follow-up might be needed. In the case of certain drug errors, we might need to advise the client’s GP so they can monitor or alter treatment as necessary. All external communications and notifications are coordinated by the Registered Manager or quality manager. Additionally, under Duty of Candour requirements, if the incident meets the definition of a “notifiable safety incident” (which usually means it resulted in moderate or severe harm, or death), we will provide a written notification to the person we support or their representative documenting the error, its effect, and giving an apology, and we will keep a copy of this correspondence​.

7. Learning and Continuous Improvement: After the immediate incident has been dealt with and investigated, {{org_field_name}} reviews what happened to improve our systems. We look at whether our current policies were followed and if not, why. Perhaps the procedure needs clarification, or maybe everything was done right but an unpredictable error occurred – either way, we consider what preventative measures can be taken. This could result in updating this Medication Policy, providing targeted training sessions (for example, a workshop on administering eye drops properly if that was a problematic area), or investing in tools to help (maybe using color-coded medicine administration times on MAR charts to avoid time errors or implementing electronic systems). We also track medication errors over time as part of our quality monitoring. The frequency and type of errors are analysed: if we notice a pattern (e.g., multiple errors with the same client or same medication), we will take proactive steps such as a case review or additional support for that client or staff. Conversely, identifying that we have very few errors and a lot of reports of “near-misses” might indicate a healthy reporting culture where staff catch issues before they affect the client – which we encourage. Our aim is to create an environment where staff feel comfortable reporting mistakes or near-misses without fear, understanding that this honesty helps everyone receive safer care. As guided by NICE and CQC, we maintain robust processes for identifying, reporting, reviewing, and learning from medicines-related incidents​. Regular summaries of incidents and lessons learned are shared with the care team (for learning) and with senior management and trustees (for oversight). In supervision meetings, medication management is a standing agenda item, allowing any individual issues to be addressed. Overall, every error or near-miss is an opportunity to improve our service, and we are committed to continually refining our practices to minimise the risk of future errors.

8. Handling and Administering PRN (“As Needed”) Medication

PRN medications (from the Latin “pro re nata” meaning “as the situation arises”) are those that are not scheduled at regular times but are given in response to specific symptoms or situations. Examples include pain relievers, laxatives, or anxiety medications that a service user only takes when they feel they need it. Proper management of PRN medication is vital to ensure that clients get relief when they need it while preventing overuse or omission. Our approach to PRN medication includes clear guidelines on when to give it, how to decide, and how to record it:

• Clear Protocols for When to Give PRN: Each service user who has PRN medication will have details in their care plan or MAR chart specifying under what conditions that medicine should be used. The prescribing doctor or pharmacist usually provides directions that should be on the medication label and/or the MAR chart. For example: “Take 1 tablet as needed for pain (moderate to severe headache), with a minimum interval of 4 hours between doses, not to exceed 4 tablets in 24 hours.” Staff must familiarise themselves with these instructions so they know the purpose of the drug, the allowed dosage range, and the minimum time gap between doses​. If this information ever seems unclear or is missing, the staff should ask a supervisor or contact the pharmacy for clarification before administering the PRN medication. We avoid any guesswork with PRNs – instructions must be unambiguous.

• Assessing the Need: The decision to give a PRN medication should ideally involve the service user. If the client is able to communicate, staff should ask them about their symptoms. Example: “Are you feeling pain right now? Do you think you need your pain relief tablet?” The client’s request or consent is important; some individuals will proactively ask for their PRN medication when they feel they need it, while others may need to be asked. If the client cannot clearly communicate (due to dementia or other issues), the care worker must use their observation skills and knowledge of the client. Look for signs of the problem that the PRN treats (e.g., signs of pain like grimacing, holding a body part, increased heart rate, or signs of anxiety like pacing, agitation). Also, refer to any PRN protocols in the care plan – often, nurses or doctors will have written guidance like “If John appears to be in pain (e.g., facial expression, vocalisation), it is appropriate to offer PRN pain medication.” When in doubt about the need, the care worker should consult a senior or a healthcare professional. It’s better to check than to either give a PRN unnecessarily or hold back when it’s needed.

• Checking Timing and Previous Doses: Before administering a PRN dose, staff must check the time of the last dose of that same medication. This includes checking the current day’s MAR chart and, if relevant, asking the client if they took any dose earlier (in case another carer or a family member might have given a dose before staff arrived). This is critical to avoid giving doses too close together or exceeding the maximum allowed. For instance, if a client has a PRN sedative that can be given “up to twice a day,” the carer should ensure it hasn’t already been given twice. If the maximum dose for 24 hours has been reached, do not give any more, even if the client is requesting it – instead, explain the situation and possibly contact a healthcare professional to see if an alternative can be arranged for relief. Likewise, if not enough time has passed since the last dose (e.g., only 2 hours since a pain tablet that needs 4-hour gaps), the carer should gently inform the client it’s too early and perhaps offer a non-medication comfort measure in the meantime (like a warm compress for pain, etc., per care plan). Adhering to these rules prevents overdosing and adverse effects​.

• Administering the PRN Medication: If it is determined that the PRN medicine is needed and safe to give (criteria met, appropriate timing), the care worker will administer it following the usual safe procedures (check the 5/6 Rights, prepare the medication correctly). Only one dose should be given at a time according to the instructions – never give more on the assumption “they might need it later.” PRN meds are strictly on an as-needed basis. While administering, it’s good practice for the carer to mention to the client what the medication is for (“Here is your inhaler for shortness of breath, since you’re feeling wheezy”) so the client is informed and can confirm if that’s what they want. If the client at that moment says they don’t actually want or need it, then don’t force it – maybe their condition changed. PRN stands for giving when needed, not automatically. After giving the medication, make sure the client is comfortable and monitor for any immediate reaction if it’s something that might act quickly (for instance, some pain meds might cause dizziness – be aware to assist the client if they stand up, etc.).

• Documentation of PRN Use: Every administration of a PRN medication must be recorded clearly on the MAR chart at the time of administration. Because PRNs are not given at regular times, the exact time of administration should be written in the MAR (if the MAR has a pre-printed time slot, write the time next to your initials or in the notes section). Additionally, staff should record the reason it was given. Many MAR charts have a back page or a separate PRN recording sheet for notes – there, the care worker should write an entry such as: “2pm: Given 5ml Lactulose – client reported constipation, last bowel movement 3 days ago.” or “8pm: 1 tablet Paracetamol 500mg given for headache (client requested; pain rated 6/10)”. Later, or at the end of the visit, it is also good practice to record in the daily care notes that a PRN was given and what the outcome was observed. For example, “By 8:30pm, client’s headache improved and she was resting.” This helps the next staff or healthcare professional see the effect. Documentation creates a trail that can be reviewed by supervisors or medical professionals to assess how often PRN meds are being used and whether the care plan needs any adjustment (e.g., if a PRN painkiller is used every single day, the GP might decide to put the client on a regular pain medication instead).

• Decision Authority and Support: Generally, the trained care staff will make the judgment call to administer PRN medication in line with the care plan guidelines and the client’s immediate needs. However, they are not alone in this decision – they have support. If ever unsure, they should call a supervisor or the on-call nurse (if we have nursing support) for advice. The care plan might also specify if any PRN decisions need to be authorised by a nurse or if the client’s family wants to be informed. For instance, some protocols say “Contact district nurse if more than 2 doses of PRN glyceryl trinitrate spray are needed in 24 hours for chest pain.” Staff should be aware of such instructions. In normal circumstances, if everything is clear (client is in pain, has order for PRN paracetamol, hasn’t exceeded dose, etc.), the care worker gives it and then informs the team via documentation. If the PRN medication is of a critical nature (like emergency medication for seizures or an EpiPen for allergic reaction), there should be explicit training and instructions for those scenarios, and staff must follow those emergency protocols, including calling emergency services when such medications are used.

• Monitoring and Review of PRN Usage: The use of PRN medications is reviewed during care reviews and also monitored in our monthly audits. We watch out for patterns: if a client never uses a PRN that’s prescribed, during the care plan review we might ask the GP if it’s still needed on the prescription. If a client is using a PRN very frequently or in increasing amounts, that triggers a review as well – staff should flag this to the manager, who may communicate with the GP. Our aim is to ensure the client’s health is managed optimally; frequent PRN use might mean their condition has changed and the regular prescription needs updating. All these considerations ensure PRN medicines are used appropriately – enough to address needs but not so much that they cause other issues.

STOMP – Preventing Over-Medication and Inappropriate Chemical Restraint

{{org_field_name}} is committed to the principles of STOMP (Stopping Over Medication of People with a learning disability, autism or both).

STOMP aims to ensure that people receive appropriate medication for clinically justified reasons, are not unnecessarily prescribed psychotropic medicines and are supported to enjoy good health, independence and quality of life.

Psychotropic medicines include antipsychotics, antidepressants, anxiolytics, sedatives and other medicines affecting mood, behaviour or mental functioning.

These medicines may be clinically appropriate for diagnosed conditions or other justified indications. However, medicines must never be used simply to make a person easier to support, suppress their communication, punish emotional reactions or control behaviour for staff convenience.

Staff Procedure: Responding to Communication, Distress and Emotional Reactions

Step 1 – Recognise the person’s communication and assess immediate safety

When an autistic person or a person with a learning disability becomes distressed, anxious, agitated, withdrawn or displays behaviour that staff find challenging, staff must:

• Remain calm and use a respectful, non-threatening approach.
• Assess whether the person or anyone else is at immediate risk of harm.
• Recognise that behaviour may be a form of communication.
• Avoid assuming that distress or an emotional reaction requires medication.
• Consult the person’s communication passport, care plan and Positive Behaviour Support (PBS) plan.

Step 2 – Identify possible unmet needs and causes of distress

Staff must consider whether the person may be experiencing:

• Pain, illness, constipation or other physical discomfort.
• Hunger, thirst, tiredness or toileting needs.
• Sensory overload caused by noise, lighting, smells, crowds or touch.
• Anxiety, fear, frustration or difficulty understanding what is happening.
• Changes in familiar routines, environments or staff.
• Communication difficulties or an inability to express choices or preferences.
• Medication side effects or changes in physical or mental health.

Staff must use the person’s preferred communication method and allow sufficient time for them to express their needs.

Where there are signs of acute illness, severe pain, sudden changes in presentation or another urgent clinical concern, staff must seek prompt medical assessment rather than attributing the presentation to autism or learning disability.

Step 3 – Provide person-centred support without medication

Where safe and appropriate, staff must use the person’s agreed non-medication strategies, which may include:

• Reducing noise, lighting or other sensory triggers.
• Offering reassurance using familiar words, gestures or communication aids.
• Allowing processing time, personal space and opportunities to make choices.
• Supporting access to a quieter or familiar environment.
• Offering preferred activities, comfort items or relaxation strategies.
• Addressing identified physical or emotional needs.
• Following agreed Positive Behaviour Support strategies.

Staff must observe the person’s response and adapt their approach accordingly.

Non-medication interventions must not delay urgent medical assessment or emergency treatment where clinically necessary.

Step 4 – Consider whether prescribed PRN medication is clinically indicated

If distress continues, staff must consult the person’s individual PRN protocol, care plan and MAR before considering medication.

PRN psychotropic medication may only be administered when:

1. The medicine has been prescribed for that individual.
2. The circumstances meet the documented clinical indication.
3. Appropriate non-medication interventions have been considered or attempted, unless the clinical circumstances require otherwise.
4. The prescribed dose, route, minimum interval and maximum dose have been checked.
5. Consent and relevant Mental Capacity Act requirements have been addressed.
6. The staff member is trained, competent and authorised to administer the medication.
7. Any required clinical advice or authorisation has been obtained.

If instructions are unclear, staff must seek clarification from the prescriber or appropriate healthcare professional before administering medication.

Staff must never administer PRN psychotropic medication solely because a person is upset, expressing frustration, refusing support or displaying behaviour that staff find difficult to manage.

Step 5 – Respond appropriately to immediate risk

Where there is an immediate risk of serious harm, staff must follow the person’s agreed emergency procedures, risk assessment and Positive Behaviour Support plan.

Staff must seek urgent clinical assistance or contact emergency services where required.

Any restrictive intervention must be lawful, necessary, proportionate and consistent with the organisation’s safeguarding and restrictive-practice procedures.

Medication must not be used as unauthorised chemical restraint.

Step 6 – Monitor and record the person’s response

Staff must record:

• The situation and circumstances preceding the distress.
• How the person communicated their feelings or needs.
• Possible contributing factors or unmet needs.
• Non-medication interventions used and their outcomes.
• Whether PRN medication was administered and the prescribed indication.
• The medicine, dose, route, time and corresponding MAR entry.
• The person’s response to medication, including effectiveness and side effects.
• Any concerns, clinical advice, escalation or safeguarding actions.

Following PRN administration, staff must monitor the person in accordance with the individual protocol, including any specified observations and review times.

Excessive sedation, breathing difficulties, serious adverse reactions or other urgent clinical concerns must be escalated immediately, with emergency services contacted where indicated.

Step 7 – Escalate concerns and arrange medication reviews

Staff must inform the Registered Manager where:

• Distress or behaviours that challenge are recurring or increasing.
• Psychotropic PRN medication is being used frequently or more often than usual.
• Medication appears ineffective or is associated with concerning side effects.
• The person appears excessively sedated or experiences reduced alertness or participation.
• There are concerns about inappropriate prescribing, over-medication or chemical restraint.

The Registered Manager must ensure concerns are communicated to the appropriate GP, prescriber or specialist learning disability service and that an appropriate clinical review is requested.

Reviews must consider the person’s wishes, clinical needs, medication effectiveness, adverse effects, quality of life and opportunities to reduce unnecessary medication.

Where antipsychotic medication is prescribed for behaviour that challenges in a person with a learning disability, the organisation must support the prescriber-led multidisciplinary review arrangements recommended by NICE, including review at 12 weeks and at least every six months thereafter.

Care staff must never independently reduce, stop or change prescribed psychotropic medicines.

Safeguarding and Reporting

Suspected inappropriate sedation, coercive medication use, deliberate over-medication or chemical restraint must be reported immediately to the Registered Manager and escalated under the Safeguarding Adults Policy.

The Registered Manager must consider whether referral to the local authority safeguarding team, CQC notification or other external reporting is required.

All concerns, decisions, referrals, actions and outcomes must be documented and reviewed.

The organisation will promote a culture in which emotional expression, communication differences and behaviours that challenge are understood and responded to through person-centred support rather than unnecessary medication.

Emergency Escalation — Immediate Danger

Where a staff member reasonably believes that an autistic person or a person with a learning disability is in immediate danger, or that another person faces an immediate risk of serious harm, they must call 999 without delay and request the appropriate emergency service.

This includes suspected life-threatening medication reactions, severe over-sedation, breathing difficulties, overdose, serious injury or another medical or safety emergency.

Staff must follow the emergency operator’s instructions, provide reassurance using the person’s preferred communication method, and take reasonable steps to maintain safety without using unauthorised restrictive interventions.

The Registered Manager or on-call manager must be informed as soon as it is safe to do so. The incident, emergency advice, actions taken and outcome must be recorded.

Where there is no immediate danger but urgent clinical advice is required, staff must contact the appropriate healthcare professional or NHS 111, in accordance with the person’s care plan and the organisation’s escalation procedures.

9. Monitoring and Reviewing Medication Practices

Medication management is not a “set and forget” aspect of our service – it requires ongoing monitoring, review, and quality improvement. {{org_field_name}} is committed to continuously reviewing how we handle medications to maintain compliance with regulations and to seek ways to improve safety and effectiveness. This section describes how we monitor our own practices (in addition to the monthly MAR audits mentioned earlier) and how we keep our policy and procedures up-to-date:

• Regular Oversight and Spot-Checks: In addition to formal monthly audits of MAR charts (Section 5), supervisors or the management team conduct random spot-checks and observations. Spot-checks might include unannounced visits or phone calls during medication rounds to ensure staff are following procedures (for example, checking that a care worker is correctly checking MAR entries, or checking that medicines support is being delivered in line with the care plan, MAR instructions and any individual risk controls). We may also occasionally shadow a care worker during a visit (with consent) to observe their medication administration technique and adherence to the policy. These spot-checks are done in a supportive way, not to “catch out” staff, but to identify any lapses in practice that can be corrected and to reinforce good practice. Findings from spot-checks (good or bad) are fed back to the staff member and recorded by management. Patterns of issues (if any) found on spot-checks will influence our training and supervision priorities.

• Management Review and Quality Assurance: The Registered Manager reviews overall medication management performance at least quarterly. This includes looking at audit results, incident reports (errors/near misses), and any feedback from service users or families about medication handling. We use a Medication Management Audit Tool aligned with CQC guidance to systematically evaluate compliance (covering storage, records, training, etc.). This higher-level review helps ensure that our policies are being implemented properly and identifies broader areas for improvement. For example, if the quarterly review finds that documentation is consistently good but storage practices could be better (maybe some homes don’t have ideal storage), the manager will initiate an improvement plan based on person-centred risk assessment, such as reviewing whether storage arrangements recorded in care plans remain appropriate. Conversely, if everything is running well, that gets noted and will be reported in management reports or CQC self-assessments as evidence of good practice.

• Monitoring Psychotropic Medication and STOMP Compliance

The Registered Manager must ensure that medication audits and management reviews include specific monitoring of psychotropic and PRN medication use for autistic people and people with a learning disability.

Monitoring must consider:

• The frequency, timing and documented reasons for PRN psychotropic medication administration.
• Whether the person’s individual PRN protocol and prescribed instructions were followed.
• Whether communication needs, sensory factors and possible unmet needs were considered.
• Whether appropriate non-medication interventions were used and documented.
• The person’s response to medication, including effectiveness, side effects and excessive sedation.
• Patterns of repeated distress, increasing medication use or changes in wellbeing.
• Whether prescribing and medication reviews are current and any recommendations have been actioned.
• Any concerns about restrictive practice, over-medication or chemical restraint.

Where concerns or patterns are identified, the Registered Manager must arrange appropriate clinical review, update care plans and risk assessments where necessary, and document an improvement action plan.

Findings must inform staff supervision, training, competency assessment and service quality improvement.

Any suspected medication-related abuse must be escalated through the safeguarding procedure without waiting for the next scheduled audit.

STOMP Review and Escalation Responsibilities

The Registered Manager must ensure that psychotropic medication used by autistic people and people with a learning disability is subject to appropriate person-centred monitoring and clinical review.

Staff must not initiate, discontinue, increase, reduce or otherwise alter prescribed psychotropic medication independently.

Where a psychotropic medicine is prescribed, the person’s care documentation must identify, where available, the clinical indication, prescribing clinician, intended outcomes, monitoring requirements, potential adverse effects and arrangements for medication review.

Where medicines are prescribed on an ‘as required’ (PRN) basis, staff must follow an individual protocol specifying the indication, dose, minimum interval, maximum permitted dose, circumstances for administration, monitoring requirements and escalation arrangements.

Staff must record the circumstances leading to PRN administration, any non-medication support offered, the reason for administration and the person’s subsequent response.

The Registered Manager must seek a review by the appropriate prescribing clinician where psychotropic medication use increases, the intended benefit is unclear, adverse effects are suspected, distress persists or the medicine appears to be used primarily to manage behaviour without appropriate clinical justification.

Reviews should consider physical and mental health needs, pain, communication barriers, sensory distress, environmental factors, Positive Behaviour Support strategies and opportunities to reduce inappropriate medication use.

The organisation must work collaboratively with the person, their prescriber, pharmacist, relevant specialists and, where appropriate, family members or advocates.

Any suspected use of medication as unlawful or inappropriate chemical restraint must be escalated immediately through safeguarding and incident-reporting procedures.

• Staff Feedback and Engagement: We consider our care staff as crucial partners in monitoring medication practices. Staff are encouraged to give feedback on the medication systems during team meetings or directly to managers. They are the ones handling medications daily and often have practical insights – for example, they might notice that a particular MAR chart layout is confusing or that timing of medication visits needs adjustment for effectiveness. We hold periodic staff meetings or training refreshers where medication management is on the agenda. In these sessions, we invite care workers to discuss challenges or suggestions. If a staff member has identified a safer way or a concern (“I think we should double-check insulin fridge temperatures weekly, just in case”), management will consider and, if appropriate, implement that suggestion. We aim for a culture of continuous improvement, where even small ideas (like adding a column for cream application on the MAR) can make a difference and are valued.

• Keeping Policies and Procedures Up-to-Date: The healthcare landscape and regulatory guidance can change, so we ensure that this Medication Management Policy is reviewed at least annually and whenever there is a significant change in relevant guidelines or regulations. For example, if NICE issues new guidance on managing medications in home care or if CQC updates its inspection criteria or if there’s a change in legislation (like controlled drug regulations), we will update our policy and inform/train our staff on the changes. The review will consider any new NICE guidelines, CQC bulletins, pharmacy advice, or sector best practices. We also incorporate lessons learned from our own operations; for instance, if an investigation into an incident reveals a gap in the policy, we will revise it. The updated policy is then redistributed to all staff (usually with a briefing on what’s changed) and old versions are archived. By keeping our policies current, we maintain compliance with the latest standards and improve the quality of care.
• Compliance and External Inspections: We regularly self-audit against the CQC’s Key Lines of Enquiry (KLOEs) for medicines management to ensure we meet all expectations. This means checking that we have evidence for things like: people’s medication needs are assessed and met, staff are trained and competent, records are complete, etc. When the CQC or local commissioners inspect or review our service, we are prepared to demonstrate our medication management performance through our audit reports, training records, and incident logs. Any feedback from such external inspections is taken very seriously. If CQC were to highlight a required improvement (for example, “improve documentation of PRN effectiveness”), we would act on it immediately and document the completed action. We strive not just to meet minimum standards, but to exceed them by proactively monitoring our service.
• Continuous Improvement Examples: Over time, the monitoring and reviewing process has led (and will continue to lead) to improvements in how we operate. Some hypothetical examples include: introducing electronic MAR (eMAR) if it’s found to reduce transcription errors, scheduling twice-yearly refresher workshops (instead of only annual) because we found knowledge dips in the second half of the year, or partnering with a pharmacist to do medicine use reviews for our clients for optimisation. We remain open to innovation in medication safety. Ultimately, the constant monitoring and review cycle ensures that medication management at {{org_field_name}} remains safe, effective, and aligned with best practice – it’s an ongoing commitment rather than a one-time effort.

10. Covert Medication, Capacity, and Consent
Covert medication refers to the practice of hiding medication in food or drink without the person’s knowledge to ensure they take it. This may only be considered when a person lacks the mental capacity to make an informed decision about taking their medication and is refusing it in a way that places them at significant risk. It must be a last resort, in the person’s best interests, and must follow a lawful process.

At {{org_field_name}}, covert medication will only be used when all of the following are in place:

• A full Mental Capacity Assessment confirms the individual lacks capacity to decide about their medication.
• A Best Interest Meeting is held with the involvement of relevant professionals (e.g., GP, pharmacist), family members, and/or an Independent Mental Capacity Advocate (IMCA) if appropriate.
• The decision and the rationale for covert medication are clearly documented in the individual’s care plan.
• Pharmacist advice is sought to determine the safest method for administering the medication covertly (some medications must not be crushed or mixed).
• A covert medication care plan is created, regularly reviewed, and includes monitoring for side effects or efficacy.
• Staff administering medication covertly are trained, competent, and fully understand the care plan instructions.

Covert medication should be regularly reviewed and withdrawn as soon as it is no longer necessary. It is not permitted without proper authorisation and documentation.

Capacity and Consent
Before any medication is administered, staff must consider whether the person has the capacity to consent. The Mental Capacity Act 2005 applies. If a person has capacity, their decision to take or refuse medication must be respected—even if that decision might seem unwise.

Where a person has capacity:

• Staff must always seek consent before administering medication.
• Consent may be implied (e.g., the person agrees when offered their medicine) or explicit (e.g., verbally agrees).
• If the person refuses, staff must record this and report to the manager, unless the refusal puts the person at immediate risk, in which case advice must be sought urgently.

Where a person lacks capacity:

• Any decision to administer medication must be in their best interests.
• Staff must follow the principles of the Mental Capacity Act and use the least restrictive option.
• If regular medication is required, a clear best interests decision must be documented in the care plan, and where appropriate, involve the family or IMCA.

Medication Audits
Medication audits are conducted regularly to ensure safe practices, compliance with policy, and accurate records. This includes:

• Monthly audits of MAR charts and controlled drug records (see Section 5).
• Spot checks and direct observations by supervisors.
• Auditing documentation related to consent, capacity assessments, and covert administration where applicable.
• Ensuring that any best interest decisions and covert medication plans are reviewed and updated.
• Recording and reviewing any medication refusals, errors, or patterns that may suggest capacity concerns.

Findings from audits are used to improve practices, update training, and ensure the ongoing safety and rights of the people we support.

11. Ensuring Service Users Maintain a Safe Supply of Medication

At {{org_field_name}}, we recognise that maintaining a continuous supply of medication is vital for the health, safety, and well-being of people using our domiciliary care service. Our responsibility extends beyond administration to supporting individuals so that they never run out of prescribed medicines. This is particularly important as, in a home care setting, service users and their families may not always be able to manage prescription requests and repeat ordering independently.

Our approach includes:

• Assessment and Care Planning:
  During the initial assessment and when developing each person’s care plan, we identify the level of support required to manage medication supplies. Some service users and/or their families will be able to order and collect their medicines independently; others may need our help to monitor supplies, request repeats, or collect prescriptions.
• Monitoring Medication Supplies:
  Care staff are required to check the supply of each medication during their regular visits. This involves visually checking packaging (e.g. counting remaining tablets in a blister pack or bottle) and checking for upcoming expiry dates. If staff notice that a supply is running low (for example, less than a week’s supply remaining), they will notify the office or person responsible as set out in the care plan.
• Supporting Prescription Requests and Repeat Ordering:
  Where a service user cannot manage reordering, or has asked us to help, staff will support them by:
  • Reminding the person or their family when repeat prescriptions are due.
  • Assisting in requesting repeat prescriptions from the GP (for example, by phone, online, or in person at the surgery), in accordance with the service user’s consent and care plan.
  • Liaising with pharmacies to arrange for timely dispensing and, where agreed, supporting collection or delivery of medication.
  • Documenting all actions related to medication ordering in the care records.
• Arranging Collection or Delivery:
  If required and agreed in the care plan, care staff can collect medication from the pharmacy on the person’s behalf, or arrange for a pharmacy delivery. All collections/deliveries are recorded, and medication is checked on receipt against the prescription and MAR chart for accuracy.
• Contingency Planning:
  If there is a risk of running out of medication (for example, due to delays in GP approval or pharmacy supply issues), staff will escalate the concern promptly to the manager. The manager will then contact the GP, pharmacy, or out-of-hours service as needed to ensure continuity of supply.
• Service User Involvement and Independence:
  Where possible, we encourage and support service users to manage their own medication supplies, in line with their abilities and preferences. For those who wish to remain independent but need reminders, staff can prompt them to order repeats and check if the order has been placed.
• Record Keeping:
  All actions relating to checking supplies, ordering, collecting, or arranging delivery of medication are documented in the daily care notes, ensuring there is a clear audit trail.

By following these procedures, {{org_field_name}} ensures that all people we support are safeguarded from the risks associated with missed or interrupted medication due to supply issues.

12. Links to Other Policies

Medication management does not stand in isolation; it is interconnected with several other areas of our care service. Staff should be aware of the following related policies, as situations involving medications might invoke these policies too:

• Safeguarding Policy: Safe medication practices are a part of safeguarding our service users from harm. Medication errors, especially if frequent or deliberate, can amount to neglect or abuse. If a staff member or anyone deliberately withholds medication, gives too much, or otherwise uses medication inappropriately to harm or control a person, this is a safeguarding issue. Our Safeguarding Adults Policy provides guidance on recognizing and reporting abuse or neglect, including medication-related concerns. For example, a pattern of missed medications could be a form of neglect that must be escalated under safeguarding procedures. Staff must refer to the Safeguarding Policy if they suspect a service user’s health is being placed at risk due to medication mismanagement.
• Whistleblowing Policy: We encourage an open culture, but if staff feel unable to report medication concerns through normal lines (perhaps because the issue involves their direct supervisor or they feel it’s being ignored), the Whistleblowing Policy offers a way to raise concerns confidentially and without fear of reprisal. This could include concerns about unsafe medication practices, such as witnessing a colleague falsifying MAR charts or stealing medication. The Whistleblowing Policy outlines how to raise such concerns with senior management or external authorities if necessary, and protects whistleblowers under UK law. Staff should remember they have this avenue if needed – it’s better to speak up about a potential medication danger than stay silent.
• Complaints Procedure: Persons we support and their families have the right to complain if they are dissatisfied with any aspect of our service, including medication management. For instance, a client might complain that they did not receive their pain medication on time, or a family member might raise a concern that medications are not being logged correctly in the MAR chart. Our Complaints Procedure explains how clients or representatives can make a complaint, how we will investigate it, and the timeframes for response. Any complaint related to medication is taken very seriously and will typically trigger a review of the medication records and practices for that client. Findings from complaints investigations might reveal areas for improvement. We treat complaints as an opportunity to remedy any wrongdoing and improve our service. Staff are expected to be cooperative and honest during any medication-related complaint investigation and to learn from the outcome.
• Other Related Policies: In addition to the three key policies above, staff should also be mindful of connections to the Health and Safety Policy (for example, safe storage of medicines is a health and safety matter, as is dealing with sharps), the Infection Control Policy (relevant when handling medications like creams, injections, or PEG tube care – use of gloves, etc.), and the Consent/Mental Capacity Act Policy (applicable when administering medication to someone who may lack capacity to consent, ensuring best interest decisions and proper authorisation for covert administration if ever needed). While these may not be explicitly listed in every context, good medication management will often require understanding those policy areas too. Regulation 13 (Safeguarding service users from abuse and improper treatment)—which requires {{org_field_name}} to prevent and respond to any medication-related abuse or improper treatment (e.g., over-sedation, coercive or inappropriate PRN use, or withholding medicines)

By understanding and following this Medication Management and Administration Policy in conjunction with related policies, {{org_field_name}} staff will ensure a holistic, safe, and person-centered approach to supporting service users with their medications. This ultimately helps the persons we support maintain their health and quality of life, and ensures we meet our regulatory responsibilities as a domiciliary care provider in England.​

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