{{org_field_logo}}

{{org_field_name}}

Registration Number: {{org_field_registration_no}}


Medication Management and Administration Policy

1. Purpose and Scope

1.1 Purpose

The purpose of this Medication Management Policy is to establish clear and robust guidelines for the safe handling, storage, administration, and disposal of medicines in domiciliary care settings. This policy ensures that all staff members adhere to best practices and legal requirements to safeguard service users’ health, well-being, and dignity while maintaining a high standard of medication management.

The policy aims to:

1.2 Scope

This policy applies to all domiciliary care staff involved in any aspect of medication management, including:

1.3 Compliance with Key Regulations and Guidance

All staff must comply with the following regulations and standards:

  1. Care Quality Commission (CQC) Regulations
    • Regulation 12 (Safe Care and Treatment): Ensures medicines are supplied in sufficient quantities, stored correctly, and administered safely​.
    • Regulation 17 (Good Governance): Requires clear governance, auditing, and risk management procedures for medication administration​.
    • Regulation 13 (Safeguarding Service Users from Abuse and Improper Treatment): Protects service users from medication-related neglect, abuse, and improper treatment​.
  2. Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
    • All domiciliary care providers must have robust procedures in place for medication safety, infection control, and staff competency.
  3. National Institute for Health and Care Excellence (NICE) Guidance
    • NICE guidance NG67: Managing medicines for adults receiving social care in the community outlines best practices for safe administration, recording, and reviewing medication management.
  4. Care Act 2014
    • The Care Act requires care providers to meet individuals’ medication needs as part of their overall care and support while ensuring person-centered care and dignity​.

1.4 Responsibilities of Staff

All domiciliary care staff involved in medication management must:

  1. Follow prescribed medication orders and only administer medication as per the service user’s Medication Administration Record (MAR).
  2. Ensure service users give informed consent before administering any medication.
  3. Encourage self-administration where possible, providing support and training as needed.
  4. Safeguard against medication errors by following the five rights of medication administration:
    • Right Person
    • Right Medication
    • Right Dose
    • Right Time
    • Right Route
  5. Report and document medication errors or refusals immediately in accordance with incident reporting procedures.
  6. Store medications securely in compliance with safety protocols (e.g., refrigeration for temperature-sensitive medications).
  7. Dispose of expired or unused medications properly, ensuring safe disposal methods to prevent misuse or environmental harm.
  8. Undergo regular training and competency assessments to ensure they remain skilled in medication administration.

2. Governance and Accountability

2.1 Overview

Effective governance and accountability in medication management ensure safe, legal, and person-centred care for service users in domiciliary care settings. Governance involves clear roles, responsibilities, oversight, and auditing processes to ensure compliance with Care Quality Commission (CQC) regulations, best practice guidance, and internal policies.

All staff must understand their individual responsibilities and the wider organisational procedures that safeguard the correct handling of medications. This includes record-keeping, audits, reporting medication incidents, and learning from errors.

2.2 Roles and Responsibilities

2.2.1 Registered Manager

The Registered Manager holds ultimate responsibility for medication governance and must:

2.2.2 Care Staff (Support Workers, Carers)

Care staff responsible for administering or assisting with medications must:

2.2.3 Office Staff / Coordinators

Office-based staff supporting medication processes must:

2.3 Compliance with Regulation 17 (Good Governance)

Regulation 17 – Good Governance requires effective systems and processes to ensure safe medication management, including:

  1. Accurate Record-Keeping:
    • All medications must be clearly recorded on a MAR chart.
    • Any changes to medication must be documented and communicated.
    • Errors or missed doses must be reported and investigated.
  2. Continuous Improvement:
    • Regular medication audits must be conducted to identify issues, trends, or risks.
    • Feedback from staff and service users must be used to enhance medication management.
    • Staff training must be updated in response to new regulations or emerging risks.
  3. Risk Assessments:
    • Each service user should have an individual medication risk assessment to identify potential hazards.
    • Storage and disposal of medicines should be regularly checked to prevent contamination, theft, or misuse.

2.4 Conducting Regular Audits & Risk Assessments

To ensure safe medication management, regular audits and risk assessments must be carried out, including:

2.4.1 Monthly Medication Audits

2.4.2 Individual Risk Assessments

2.5 Adherence to Regulation 20 (Duty of Candour)

Regulation 20 – Duty of Candour requires openness and transparency in the event of medication-related incidents.

2.5.1 Reporting Medication Incidents

Any medication errors, near-misses, or adverse reactions must be:

  1. Immediately recorded in the incident log.
  2. Reported to the Registered Manager.
  3. Investigated to determine the cause and prevent future occurrences.
  4. Communicated to the service user and/or their family in a clear and transparent manner.
  5. Reported to CQC if required.

How to report:

1) Verbally

2) Inform the Registered Manager by email: {{org_field_registered_manager_email}}

3) Call the office: {{org_field_phone_no}}

4) Out of hours phone number: {{out_of_hours}}

5) Fill in a Medication Error Report form which can be obtained from the office.

2.5.2 Learning from Medication Errors

After a medication incident, a review meeting should be held to:

2.6 Continuous Improvement & Staff Training

3. Medicine Supply and Stock Control

Effective medicine supply and stock control is essential to ensure that service users receive the correct medication at the right time, in the right dose, and in the correct condition. All domiciliary care staff must follow strict procedures to prevent medication errors, shortages, and wastage while complying with Care Quality Commission (CQC) regulations, the Health and Social Care Act 2008, and NICE guidance.

3.1 Ensuring Adequate Stock Levels of Prescribed Medicines

To ensure that service users do not run out of essential medications:

3.2 Procedure for Ordering, Receiving, and Checking Medicines

Proper ordering, receiving, and checking of medicines ensures accuracy, safety, and compliance with prescriptions.

3.2.1 Ordering Medicines

3.2.2 Receiving Medicines

3.2.3 Checking Medicines

Upon receiving new medication:

3.3 Recording Medication Supply and Checking Expiry Dates

3.3.1 Recording Medication Supply

3.3.2 Checking Expiry Dates

3.4 Safe Disposal of Unused or Expired Medicines

To prevent misuse and ensure environmental safety:

3.5 Responsibilities of Staff in Medicine Supply and Stock Control

Care Staff:

Office Staff / Coordinators:

Registered Manager:

4. Safe Medication Management

Safe medication management is a critical part of providing high-quality care and ensuring the well-being of service users. All staff must follow strict procedures when handling, storing, administering, and documenting medication use. This section provides clear instructions on administration procedures, storage requirements, and handling medication errors and omissions.

4.1 Administration Procedures

Proper administration of medication is essential to prevent errors, ensure effectiveness, and maintain safety. All care staff must adhere to Regulation 12 (Safe Care and Treatment)​to ensure medicines are handled correctly.

4.1.1 Following Regulation 12 (Safe Care and Treatment)

4.1.2 Ensuring Correct Dosage, Timings, and Administration Routes

4.1.3 Observing for Side Effects and Adverse Reactions

4.2 Storage Requirements

Proper medication storage is essential to maintain potency, prevent contamination, and ensure compliance with legal regulations.

4.2.1 Secure Storage of Controlled Drugs

4.2.2 Safe Storage of Medical Gases and Emergency Medicines

4.2.3 Proper Temperature Control for Medications Requiring Refrigeration

4.3 Medication Errors and Omissions

Despite strict procedures, errors can still occur. It is vital that staff follow clear reporting and corrective action protocols to protect service users.

4.3.1 Immediate Reporting and Documentation of Medication Errors

A medication error occurs when:

What to do if an error occurs:

  1. Assess the service user – check for any signs of harm or adverse reactions.
  2. Report immediately to the registered manager or supervisor.

Where to report:

a) Verbally

b) Inform the Registered Manager by email: {{org_field_registered_manager_email}}

c) Call the office: {{org_field_phone_no}}

d) Out of hours phone number: {{out_of_hours}}

  1. Contact emergency services (999) if necessary.
  2. Document the incident in the MAR chart and incident report log.
  3. Follow the investigation process to prevent recurrence.

4.3.2 Procedures for Handling Missed Doses or Incorrect Administration

4.3.3 Investigation and Corrective Actions in Line with CQC Regulations

4.4 Staff Responsibilities in Safe Medication Management

All Care Staff Must:

Registered Manager Must:

5. Administration of Medicines in Service Users’ Homes

The safe administration of medicines in a service user’s home is essential to ensuring their well-being, maintaining their dignity, and promoting their independence. Staff must follow all legal and regulatory requirements while ensuring that medication is administered correctly and safely.

5.1 Gaining Informed Consent Before Administering Medication

Before administering any medication, staff must ensure that the service user has given informed consent. This means that the individual has been provided with all relevant information about their medication, understands the purpose, benefits, and potential risks, and agrees to take it.

  1. Always explain to the service user:
    • What the medication is for
    • The correct dosage and timing
    • Any potential side effects or reactions
  2. Ensure that the service user is able to provide consent. If they lack the capacity to do so, staff must:
    • Follow the guidelines set out in the Mental Capacity Act 2005
    • Involve family members or legal representatives if necessary
    • Document the decision-making process in the service user’s care records
  3. If a service user refuses medication:
    • Do not force or pressure them
    • Record the refusal in the Medication Administration Record (MAR)
    • Inform the registered manager or healthcare professional if refusals are frequent or pose a risk to the service user’s health

5.2 Encouraging Service Users to Self-Administer Where Possible

Maintaining independence is a key aspect of person-centered care. Where appropriate, service users should be supported to manage their own medication, either fully or partially.

  1. Assess whether self-administration is appropriate:
    • Consider the service user’s ability to remember dosages and handle medication safely
    • Check if there are any risks associated with self-administration
    • Document the assessment and review regularly
  2. Provide support based on the service user’s needs:
    • Full self-administration – The service user takes full responsibility for managing their medication
    • Prompting – Staff remind the service user to take their medication but do not physically assist
    • Supervision – Staff observe the service user taking their medication to ensure it is taken correctly
    • Partial assistance – Staff may help with tasks such as opening containers or preparing doses but do not physically administer the medication
  3. If a service user’s ability to self-administer changes:
    • Conduct a reassessment
    • Implement additional support or supervision if required
    • Update the service user’s care plan and MAR chart

5.3 Procedures for Staff Assisting with Medication

When assisting service users with medication, staff must ensure they follow safe and correct procedures at all times.

  1. Prompting Medication
    • Remind the service user when it is time to take their medication
    • Do not touch or administer the medication unless the care plan specifies assistance
  2. Supervising Medication
    • Observe the service user taking their medication and ensure they follow the correct procedure
    • Record that the medication has been taken in the MAR chart
  3. Administering Medication
    • Check the MAR chart to ensure the correct medication, dose, time, and route
    • Ensure the service user is in a comfortable position before administration
    • Offer a drink of water if required to swallow tablets
    • Do not crush or alter medication unless instructed to do so by a healthcare professional
    • Remain with the service user until they have taken the medication
    • Document the administration immediately in the MAR chart

5.4 Maintaining Accurate Medication Administration Records (MAR)

Accurate record-keeping is essential for medication safety, compliance, and auditing purposes. The MAR chart must be completed for every medication administered, prompted, or supervised.

  1. Completing the MAR Chart
    • Clearly record the date, time, and dose of medication given
    • Use the correct codes to indicate whether the medication was administered, refused, or omitted
    • Ensure entries are made in real-time, never before or after the actual administration
  2. Documenting Changes or Issues
    • If a service user’s medication is changed by a GP, update the MAR chart and notify the office
    • If a service user refuses medication, record the refusal and report it to the registered manager if necessary
    • Record any errors, missed doses, or adverse reactions and follow the appropriate reporting procedures
  3. Auditing and Reviewing MAR Charts
    • MAR charts should be checked regularly by senior staff to identify any discrepancies
    • Any issues identified should be investigated and addressed immediately
    • Records must be stored securely and retained for the required period as per regulatory guidelines

6. Record-Keeping and Audit Process

Effective record-keeping and regular auditing are essential to maintaining safe medication management and ensuring compliance with regulatory requirements. All staff involved in medication administration must understand the importance of accurate documentation and proactive monitoring of medication processes.

6.1 Keeping Accurate and Up-to-Date MAR Charts

Medication Administration Records (MAR) charts are legal documents that provide a detailed record of all medications administered to a service user. Staff must ensure that MAR charts are completed accurately and kept up to date to prevent medication errors and ensure continuity of care.

  1. Recording Medication Administration Correctly
    • Every time a medication is administered, prompted, or refused, it must be recorded immediately in the MAR chart.
    • Entries must be made in real time. Never fill out MAR charts in advance or leave entries incomplete.
    • Ensure that the following details are recorded:
      • Date and time of administration
      • Name of the medication
      • Dose given
      • Route of administration (oral, topical, injection, inhalation)
      • Name and signature of the staff member administering the medication
  2. Using Correct Notation and Codes
    • Only use approved medication codes when recording administration, refusal, or omissions.
    • If a medication is refused or missed, a reason must be documented clearly.
    • If an error is made on the MAR chart, it should not be erased. Draw a single line through the error, write “error,” and sign it.
  3. Documenting Missed or Refused Doses
    • If a service user refuses a medication, encourage them to take it and explain why it is important.
    • If they still refuse, do not force them. Record the refusal in the MAR chart and notify the appropriate person (e.g., registered manager, GP, or family member if necessary).
    • If a dose is missed for any reason, document the reason in the MAR chart and report it immediately.
  4. Handling Changes in Medication
    • If a GP or healthcare professional changes a prescription, ensure the MAR chart is updated immediately.
    • Remove or mark previous medication instructions as discontinued to prevent errors.
    • Verify the new medication details with the pharmacy before administration.

6.2 Regular Medication Audits to Ensure Compliance

Regular audits of medication administration records and stock help identify errors, ensure compliance with policies, and improve safety.

  1. Weekly MAR Chart Checks
    • Senior staff or the registered manager should review all MAR charts weekly to check for:
      • Missing entries or incomplete records
      • Errors in documentation
      • Consistency between prescribed medication and what has been administered
  2. Monthly Full Medication Audits
    • Conduct a full audit of all medication administration records, stock levels, and storage practices.
    • Verify that controlled drugs are recorded correctly in the controlled drugs register.
    • Check for expired medications and ensure proper disposal procedures are followed.
  3. Incident Review and Reporting
    • Any medication-related errors, missed doses, or discrepancies identified during an audit must be reported and investigated.
    • Staff involved in errors must receive additional training if needed to prevent future mistakes.
    • Findings from audits should be shared with staff, and any corrective actions must be documented and implemented.

6.3 Ensuring All Medication Changes Are Documented and Communicated to Relevant Professionals

It is essential that all changes in a service user’s medication regimen are clearly documented and communicated to the appropriate professionals to maintain continuity of care.

  1. Updating MAR Charts and Care Plans
    • When a medication is added, stopped, or the dose is changed, the MAR chart must be updated immediately.
    • The new prescription must be checked against the original order to confirm accuracy.
  2. Notifying the Relevant Professionals
    • The registered manager must ensure that all medication changes are communicated to:
      • The GP or prescribing healthcare professional
      • The pharmacy supplying the medication
      • The service user and their family or advocate, if appropriate
    • If a change in medication affects the service user’s health or care needs, update their care plan accordingly.
  3. Ensuring Staff Awareness
    • Staff must be informed of any changes in a service user’s medication regimen before administering medication.
    • A handover process should be in place to ensure that all care workers on duty are aware of recent changes.
    • Any uncertainty about a medication change must be clarified with the registered manager or healthcare professional before administration.

7. Staff Training and Competency Assessment

Staff training and ongoing competency assessments are essential to ensure that medications are administered safely and in compliance with legal and regulatory requirements. All staff involved in medication management must be trained and assessed regularly to maintain high standards of care and prevent medication errors.

7.1 Mandatory Medication Training

All staff responsible for administering, assisting with, or managing medications must complete a formal training program before undertaking these responsibilities. Training must include:

  1. Understanding Medication Management Regulations and Policies
    • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
    • Care Quality Commission (CQC) medication standards
    • National Institute for Health and Care Excellence (NICE) guidelines on medication safety
  2. Types of Medications and Their Uses
    • Commonly prescribed medications and their effects
    • Routes of administration (oral, topical, injection, inhalation)
    • Differences between prescription-only medications, over-the-counter drugs, and controlled substances
  3.  
  4. Safe Medication Administration Procedures
    • How to check and use a Medication Administration Record (MAR) chart
    • The five rights of medication administration: right person, right medication, right dose, right time, and right route
    • Handling, measuring, and preparing medications correctly
    • Preventing and responding to medication errors
  5.  
  6. Recognising and Managing Side Effects and Adverse Reactions
    • Signs of an allergic reaction
    • Common side effects of different medications
    • When to seek medical advice or emergency help
  7.  
  8. Legal and Ethical Responsibilities
    • Obtaining informed consent before administering medication
    • Service user rights in relation to medication decisions
    • Safeguarding considerations when handling medications

7.2 Competency Assessments at Regular Intervals

Competency assessments must be conducted to ensure that staff have the necessary skills and knowledge to administer medications safely. These assessments should take place:

The competency assessment should include:

  1. Practical Demonstration of Medication Administration
    • Checking the MAR chart and identifying the correct medication
    • Administering medication following the correct procedure
    • Recording medication administration accurately
  2. Knowledge Check on Medication Safety
    • Understanding medication side effects and interactions
    • Knowing how to respond to a medication refusal
    • Correct procedures for reporting medication errors
  3. Observation and Supervision
    • Senior staff should observe new or recently trained staff administering medications
    • Feedback should be provided, and any areas for improvement should be addressed
    • Staff must be retrained if any gaps in knowledge or practice are identified

7.3 Training on the Use of Controlled Drugs, Medical Gases, and Emergency Medications

Some staff members may be required to administer controlled drugs, medical gases, or emergency medications. Additional specialized training is required for these areas.

  1. Controlled Drugs (CDs)
    • Understanding the legal framework for controlled drugs, including record-keeping requirements
    • Safe storage, handling, and administration of controlled drugs
    • Completing the controlled drugs register correctly
    • Disposal procedures for unused controlled substances
  2. Medical Gases (e.g., Oxygen Therapy)
    • Safe storage and handling of medical gases
    • How to administer oxygen therapy safely
    • Identifying service users who require oxygen and understanding their care plans
  3. Emergency Medications (e.g., EpiPens, Naloxone, Glucagon)
    • When and how to administer emergency medications
    • Recognizing the symptoms of anaphylaxis, hypoglycaemia, and opioid overdose
    • Ensuring emergency medications are stored correctly and checked for expiry dates

8. Compliance with National Guidance

All staff involved in medication management must follow national guidance to ensure safe, legal, and effective practices. Compliance with established guidelines helps prevent medication errors, safeguard service users, and ensure the highest standards of care. Staff must understand and adhere to the relevant regulations, including NICE guidelines, CQC standards, and safeguarding requirements under Regulation 13.

8.1 National Institute for Health and Care Excellence (NICE) Guidelines on Medication Management

The National Institute for Health and Care Excellence (NICE) provides evidence-based recommendations for the safe handling, administration, and management of medicines in social care settings. Staff must follow NICE guidance to ensure that all medication-related activities align with best practices.

  1. Person-Centered Approach to Medication
    • Ensure that service users are involved in decisions about their medication whenever possible.
    • Respect individual preferences, including cultural and religious beliefs related to medication.
    • Encourage and support service users to self-administer if they are capable and it is safe to do so.
  2. Safe Handling and Storage of Medicines
    • Ensure that all medications are stored securely and at the correct temperature.
    • Maintain a system for tracking and managing medication stock levels.
    • Check expiry dates regularly and dispose of expired medications safely.
  3. Administration of Medication
    • Follow proper procedures for checking prescriptions, MAR charts, and medication labels.
    • Adhere to the five rights of medication administration: right person, right medication, right dose, right time, and right route.
    • Document all medication administration accurately and immediately after it is given.
  4. Monitoring and Review of Medication
    • Regularly review service users’ medications to ensure they remain appropriate and effective.
    • Report and document any side effects, adverse reactions, or changes in health conditions.
    • Communicate with healthcare professionals to make adjustments to medication as needed.

8.2 Compliance with CQC Fundamental Standards for Medication Safety

The Care Quality Commission (CQC) sets out fundamental standards that all care providers must meet. Compliance with these standards ensures that service users receive safe and effective care, particularly in relation to medication management.

  1. Safe Care and Treatment (Regulation 12)
    • Ensure that medications are supplied in sufficient quantities and administered correctly.
    • Prevent errors by following standardized procedures for checking, preparing, and administering medication.
    • Train and assess staff regularly to maintain high standards of medication safety.
  2. Good Governance (Regulation 17)
    • Maintain clear policies and procedures for medication management.
    • Conduct regular audits and quality checks to identify and correct any issues.
    • Keep accurate and detailed records of all medication activities, including administration, storage, and disposal.
  3. Duty of Candour (Regulation 20)
    • Be open and transparent with service users and their families regarding medication errors or incidents.
    • Report serious medication-related issues promptly to the registered manager and CQC if required.
    • Take corrective action following medication incidents to prevent recurrence.

8.3 Adherence to Regulation 13 (Safeguarding Service Users from Abuse and Improper Treatment) to Prevent Medication-Related Abuse

Regulation 13 ensures that service users are protected from abuse, including medication-related abuse or neglect. All staff must understand their role in safeguarding service users from harm and must take immediate action if they suspect abuse.

  1. Identifying Medication-Related Abuse
    • Be aware of the different forms of medication-related abuse, including:
      • Overmedication (giving unnecessary or excessive medication).
      • Under-medication (failing to give required medication or intentionally reducing doses).
      • Withholding medication as a form of control or punishment.
      • Giving medication without proper consent.
    • Look for signs that a service user may be experiencing medication-related abuse, such as unexplained drowsiness, agitation, confusion, or deterioration in health.
  2. Taking Action if Abuse is Suspected
    • If a staff member suspects that a service user is being abused or neglected in relation to their medication, they must:
      • Report their concerns to the registered manager immediately.
      • Document the concern in the service user’s records.
      • Follow the organization’s safeguarding procedures, including reporting to external authorities if necessary.

Where to report:

1) Inform the Registered manager verbally

2) Inform the Registered Manager by email: {{org_field_registered_manager_email}}

3) Call the office: {{org_field_phone_no}}

4) Out of hours phone number: {{out_of_hours}}

5) Care Quality Commission (CQC): Call03000 616161 for concerns about care standards or regulatory breaches.

6) Local Authority Adult Safeguarding Teams: {{org_field_local_authority_authority_name}}, Link: {{org_field_local_authority_information_link}} for concerns related to abuse or neglect.

  1. Preventing Medication-Related Abuse
    • Ensure that all medication administration follows legal and ethical guidelines.
    • Train staff to recognise and report signs of medication-related abuse.
    • Maintain proper documentation to ensure transparency and accountability in medication management.

10. Review and Policy Updates


Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

Leave a Reply

Your email address will not be published. Required fields are marked *