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DCW21-Medication Management and Administration Policy

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Medication Management and Administration Policy

Introduction and Purpose

This Medication Management and Administration Policy outlines how {{org_field_name}} ensures the safe handling of medicines for individuals receiving care in their own homes. The purpose of this policy is to promote safe, effective, and person-centred medication support in compliance with all relevant laws, regulations, and best practice guidance in Wales. It provides clear instructions for care staff to follow when assisting with or administering medications, in order to protect the well-being, dignity, and rights of service users.

This policy is written in accordance with the requirements of the Regulation and Inspection of Social Care (Wales) Act 2016 and the accompanying Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017. In particular, Regulation 58 of the 2017 Regulations requires domiciliary care providers to have robust arrangements for the safe storage, administration, recording, auditing and disposal of medicines. The policy also reflects the statutory guidance issued under the 2016 Act (updated in 2023) which sets out what “good” looks like in medicines management for regulated services.

In developing this policy, {{org_field_name}} has taken into account the NICE Guideline NG67: Managing Medicines for Adults Receiving Social Care in the Community, which provides evidence-based recommendations on supporting people with their medicines at home. The policy is aligned with the Social Care Wales Code of Professional Practice for social care workers, which emphasizes safe and accountable practice (e.g. maintaining clear records and only working within one’s competence). Where applicable, reference is also made to Welsh Government guidance and quality standards (including any relevant updates in 2024) to ensure the policy meets Care Inspectorate Wales (CIW) expectations and current best practice.

Overall, the goal of this policy is to enable care staff to safely manage and administer medications, while empowering individuals to be as independent as possible with their own medicines. It provides a framework for consistent practice, risk management, and continuous improvement in medication management across {{org_field_name}}’s services.

Scope and Legal Framework

Scope: This policy applies to all staff of {{org_field_name}} who are involved in any aspect of medication support or administration in a domiciliary (home care) setting. This includes care workers, supervisors, managers, and any other personnel handling service users’ medication as part of their role. It covers the entire process of medicines management in the service user’s home – from assessing medication needs and planning support, through safe storage, administration (or assistance with self-administration), recording, and disposal of medicines. The policy is relevant for all types of medication (prescribed and certain non-prescribed remedies agreed in care plans), including oral medicines, topical preparations, inhalers, injections (when these fall under care staff duties via delegation), controlled drugs, and “as needed” (PRN) medications. It does not cover the administration of medications to staff or the handling of medications outside the context of service users’ care.

Legal and Regulatory Framework: This policy operates under the legislative framework governing social care services in Wales. Key elements of this framework include:

Responsibility: The Responsible Individual (RI) for {{org_field_name}} holds overall accountability for ensuring compliance with this policy and the above legislation. The Registered Manager is responsible for the day-to-day implementation, including staff training and monitoring of medicines management. All care staff must adhere to this policy at all times and report any deviations, errors, or risks to the management immediately. Compliance with the medication policy is a condition of employment, and any breach may result in retraining or disciplinary action, as appropriate, to maintain the safety of service users.

 

Principles of Safe Medication Practice

Person-Centred Approach: Medication support will be delivered in a person-centred manner, respecting each individual’s rights, preferences, and dignity. Care workers will involve the service user (and their family/carers where appropriate) in decisions about how they prefer to take their medicines. Wherever possible, individuals will be enabled and encouraged to maintain independence in managing their own medication, with the care worker’s role being to support or assist rather than take over completely. The individual’s consent will be sought for any assistance or administration of medicines each time, and their right to refuse a medication is respected (unless refusing poses a serious and immediate risk, in which case advice from healthcare professionals will be sought). The Social Care Wales Code and Welsh standards emphasize maximizing the individual’s control and involvement in their care, so this ethos underpins all medication-related tasks.

Safety and the “Five Rights”: Care staff will follow the fundamental principles of safe medication administration often summarized as the “Five Rights”: the right person, the right medication, the right dose, at the right time, by the right route. Before giving any medicine, staff must verify each of these points against the prescription label and the Medication Administration Record (MAR). In practice, this means checking the service user’s identity (especially in settings where multiple people are present, though in one’s own home identity is usually clear), reading the medication label to confirm the name and strength of the drug, comparing it to the MAR chart instructions, ensuring the timing is correct (and appropriate in relation to food or other medications), and confirming the correct method of administration (e.g. orally, topically, inhaled, etc.). Staff should also ensure the medication hasn’t expired and has been stored properly. By adhering to these checks every time, the risk of error is significantly reduced. Staff should never administer a medication if any of these “rights” cannot be confirmed – instead, they must pause and seek clarification from a manager or pharmacist before proceeding.

Compliance with Prescriptions and Scope of Practice: Only medications that have been prescribed by a qualified healthcare professional (or agreed in the care plan in the case of certain mild over-the-counter remedies) will be administered by care staff. Under no circumstances should care workers prescribe or alter dosages on their own initiative. If a service user or family member requests a change or if the care worker believes a change is needed (for instance, due to side effects or inefficacy), they must report this to their manager, who will in turn communicate with the prescriber (GP, nurse, etc.) for guidance. Care staff must work within their scope of practice: tasks such as giving injections, administering through a Percutaneous Endoscopic Gastrostomy (PEG) tube, or other specialized techniques are only permitted if a healthcare professional has specifically delegated the task, the staff have been trained and deemed competent for that specific task, and clear written procedures are in place (see Self-Administration and Specialized Techniques section). Otherwise, such medical tasks remain the responsibility of healthcare professionals. This principle is reinforced by national guidance which states that social care providers should define the circumstances in which care workers may assist or administer medications and ensure all procedures are clearly outlined.

Confidentiality and Privacy: Medication is a personal health matter. Staff will handle information about individuals’ medications confidentially, sharing details only with those who need to know (such as healthcare professionals, the care team, or regulators if appropriate). Medication administration will be conducted in a way that maintains the person’s privacy and dignity – for example, discussing medication needs discreetly, not in front of visitors without permission, and ensuring the individual is comfortable during the process (e.g., providing water to take tablets, allowing them time to take it without rush). Documentation (MAR charts, care plans) containing medication information will be kept secure and only accessed by authorized personnel.

Preventing Harm and Promoting Well-being: The overarching principle is to prevent harm while promoting the health benefits of effective medication use. Care staff should be vigilant for any adverse reactions or side effects when assisting with medication. If any concerns arise (such as rashes, excessive drowsiness, or new symptoms after a medicine), staff must report these promptly so that medical advice can be sought. Medications will be administered as intended to achieve therapeutic benefit – staff should follow any specific instructions (like giving with food or at certain times) that affect the medicine’s effectiveness. By ensuring medicines are taken correctly, we support the well-being, comfort, and health outcomes of the service user, which is a key objective under Welsh care standards and the well-being principles of the Social Services and Well-being Act. We also commit to a no-blame culture in reporting any issues (like errors or near-misses), meaning staff are encouraged to immediately report problems so that the priority is to protect the person and learn from incidents, rather than to assign blame. This openness contributes to safer practice.

Regular Review and Individualization: Principles of safe practice include regularly reviewing each individual’s medication support to ensure it remains appropriate. People’s needs and capacities can change; thus, what is safe and suitable for one month may need adjustment the next. Care plans related to medication will be reviewed at each service plan review or sooner if there are changes (e.g., hospital admissions, new diagnoses, or noted difficulties). This ensures the level of support is always tailored to current needs – for instance, increasing assistance if someone’s memory worsens, or encouraging more self-management if someone’s capability improves. Also, medication regimens themselves are subject to medical review (by GPs or pharmacists). Staff should assist service users in accessing medication reviews (for example, encouraging annual reviews or supporting communication with healthcare providers) and implement any changes in the support plan accordingly. By individualizing support and staying up-to-date, {{org_field_name}} ensures adherence to both the letter and the spirit of safe medication practice guidelines.

 

Medication Risk Assessment and Planning

Before {{org_field_name}} begins providing medication support to a new service user (or when a current user’s needs change significantly), a thorough medication risk assessment is conducted. The purpose of this assessment is to determine the level of support the person needs with their medicines and to identify any risks or special requirements. This assessment forms part of the individual’s overall needs assessment and personal plan, as required by Welsh regulations and good practice.

Assessment of Medicines Support Needs: A trained staff member (such as a supervisor or care manager) will meet with the individual (and family/carers if appropriate and with consent) to discuss how they manage their medications. Key points considered include:

This assessment process should be a conversation with the individual, not just a checklist. We engage the person in identifying what support they feel they need and what outcomes they want (for example, “I want to remember to take my pain meds so I can stay pain-free”). According to NICE guidance, it’s important to focus on how the person can be supported to manage their own medicines as much as possible. The assessor will also consult relevant health professionals (with consent) – for example, check with the GP or pharmacist to ensure we have accurate medication information, or request a medication review if things seem suboptimal (like duplicate therapies or old prescriptions).

Risk Evaluation: Using the information gathered, {{org_field_name}} evaluates the risks associated with the person’s medication management. Common risks include:

Each identified risk is rated and addressed in the support plan. For example, if memory lapses are a risk, the plan might be for care workers to provide reminders or administer medication directly. If physical dexterity is an issue, perhaps the pharmacy can provide easy-open bottles or a compliance aid (like a blister pack) and care staff will assist with packaging. If there’s a risk of overdose (say, the person forgets they took their meds and might take them again), the plan might include the care worker holding the medications securely and only giving each dose at the right time, or using a timed dispenser that only releases the right dose.

Medication Support Plan (Personal Plan): Based on the assessment, a personalized medication support plan is written as part of the individual’s overall care plan (known in Wales as the Personal Plan). This plan clearly documents:

Once drafted, this medication section of the care plan is agreed with the individual (or their representative). The service user (if able) signs or verbally agrees to the plan, acknowledging what support {{org_field_name}} will provide. We also communicate and agree the plan with relevant health professionals if needed (for example, confirming with the GP that care staff will administer a certain medication so that everyone knows their roles – NICE recommends clarifying responsibilities between social care and health services).

Review and Updates: Medication support needs are reviewed regularly. At minimum, during the formal review of the personal plan (which in domiciliary care in Wales is at least every 3 months or sooner if changes occur). However, any time there is a change in medications (new prescription, dose change, hospital discharge with a new regime), the medication list and support plan must be updated immediately. Staff should inform the office/manager of any changes they become aware of, so that records (including the MAR charts and eMAR) are kept current. If a service user’s ability to self-manage improves or declines, we don’t wait for the 3-month review – we reassess promptly and adjust the plan. Also, if we notice frequent issues (like regular refusals or errors), this triggers a review to modify the support approach or involve healthcare professionals for a solution (for instance, simplifying the regimen or switching medication form).

In summary, careful assessment and person-specific planning form the foundation of safe medication management. By identifying needs and risks upfront and tailoring a clear plan for each individual, {{org_field_name}} aims to prevent problems and ensure that medication support is delivered safely and effectively, in line with both regulatory requirements and the individual’s own wishes and best interests.

 

Safe Storage and Handling of Medication in Service Users’ Homes

Safe storage and proper handling of medicines in the service user’s home are critical to ensure medications remain effective and to prevent accidents or misuse. Unlike care homes, domiciliary care means medicines are kept in a person’s private residence, so {{org_field_name}} staff must take care to maintain safety in a less controlled environment. The following practices will be observed:

Storage Conditions: All medications should be stored in accordance with the manufacturer’s/pharmacist’s instructions (typically in a cool, dry place away from direct light, unless refrigeration is required). Care staff will advise and assist the service user to designate a safe storage location in their home. Ideally, this is a dedicated cupboard or container that is:

Controlled Drugs (CDs): Controlled drugs (like strong painkillers such as morphine, fentanyl patches, or certain anxiety medications) have higher risk of misuse and often special requirements. In a domiciliary setting, it is not usually practical to have a fixed drugs cabinet as in a care home, but extra precautions will be taken. Where a service user is prescribed a Controlled Drug:

Handling and Administration Techniques: Proper handling means using safe techniques to avoid contamination or error:

Supporting Safe Storage by the Individual: In line with promoting independence, if a person self-medicates or is transitioning to more independent management, staff will educate or remind them about safe storage. For example, explaining to a person with grandchildren that medicines should be kept out of reach of little ones, or reminding someone not to store their tablets in the kitchen next to cleaning chemicals, etc. These preventive conversations help embed safe habits. The medication risk assessment will note if a person’s living situation presents storage challenges (like no suitable high cabinet), and solutions will be sought (maybe installing a child-safe box or asking if a family member can hold onto excess medication).

Medication Reconciliation at Start of Service: As part of safe handling, when {{org_field_name}} first takes on supporting a person, a medication reconciliation is done. That means we compare what the GP says the person should be taking, what the pharmacy labels say, and what the person is actually taking or has in their home. Any discrepancies (extra old meds lying around, differences between hospital discharge notes and GP list, etc.) are sorted out. Unneeded or duplicate medicines will be identified for disposal (with the person’s agreement and in consultation with a pharmacist if needed). Going forward, after any hospital stay or doctor’s appointment where changes are made, staff will perform a mini-reconciliation: verifying changes with the GP’s orders and removing any stopped medication from the active supply (to avoid accidental use). This practice aligns with maintaining accurate records and safe handling of current medicines only.

By adhering to these safe storage and handling procedures, we ensure that medicines remain effective (not spoiled or expired), are taken by the right person only, and the risk of accidental harm is minimized. These measures meet the regulatory requirement for safe storage arrangements and follow national guidance that medication storage and administration should adhere to both statutory and good practice guidelines.

 

Administration Procedures

When administering medication, {{org_field_name}} staff will follow a standard procedure to ensure safety, accuracy, and respect for the individual. “Administration” in this context covers not only physically giving medications to someone, but also the act of prompting or assisting someone to take their own medication, as per their care plan. Below are the general steps and specific protocols for various scenarios (including PRN medications, controlled drugs, refusals, and covert administration).

General Medication Administration Steps:

  1. Preparation: Before a scheduled medication time, the care worker should prepare by reviewing the service user’s MAR chart (Medication Administration Record, or eMAR on a device) to see which medicines are due at that visit. They should also be aware of any recent changes (e.g., a new medication added by the GP, or a dose changed) – checking the communication notes or handover information for updates. Wash hands thoroughly and gather any equipment needed (medication spoon, glass of water, gloves, etc.).
  2. Identify and Inform: Greet the service user and confirm that it is time for their medication. Even if the care worker and individual know each other well, it’s good practice to ensure the person is aware and agreeable to taking their medicines at that time – this is part of obtaining consent. For example: “Good morning, I have your medications ready now – is it okay if we go ahead and take them?” If the person questions or seems unsure, the care worker should provide any information the person needs (e.g., remind them which medication is for what condition, as known from the care plan) to help them understand and agree.
  3. Check the Medication Details (The Five Rights): For each medicine due:
    • Read the MAR chart entry and then find the corresponding medication container.
    • Check label on the bottle/box: confirm the person’s name on it (right person), the medication name and strength (right medication), the dose (e.g., “two tablets of 5mg” – ensure this matches MAR), the route (e.g., oral, topical), and the time or frequency. Verify it is indeed the correct time for that dose.
    • Check the expiry date (especially for liquids, eye drops, or time-limited meds) – do not use if expired or if an eye drop has been open too long per instructions.
    • If anything doesn’t match (for instance, MAR says 1 tablet but label says take 2, or medicine looks different than usual), pause and clarify before proceeding – call the manager, pharmacy or GP as needed. NEVER guess or assume.
  4. Positioning and Assisting the Person: Ensure the individual is in an appropriate position to take medicine safely (usually sitting upright with a glass of water for oral meds). For those with swallowing difficulties, follow any Speech and Language Therapist guidance (like thickened liquids or specific posture). If administering eye/ear drops, nasal spray, inhalers, or topical creams, explain each step to the person and proceed gently, maintaining their comfort and dignity (e.g., cover areas not being treated, etc.). Always follow any specific instructions (like shake the inhaler, wait X seconds between puffs, apply cream with gloves and in a thin layer, etc.).
  5. Administration: Administer the medicine according to its route:
    • For oral tablets/capsules: either hand the dose to the person (if they are able to self-put in mouth) or, if needed, place it in a spoon or into their hand. Provide water or preferred fluid. Observe that the medication is swallowed (especially important for those with dementia who might cheek tablets – make sure they actually ingest it).
    • For liquid medicine: measure the exact dose in an oral syringe or medicine cup at eye level, ensuring accuracy. Give to the person to swallow, or assist if they need help steadying the cup.
    • For inhalers: assist the person to take the correct number of puffs with proper technique, or administer via a spacer device if they use one. Ensure they inhale at the same time as actuation if doing it for them.
    • For topical medicine (creams, ointments, patches): wear gloves, apply to the correct site as directed (e.g., “apply to left calf”), and never double-dip fingers into a jar (use a clean tongue depressor or tissue to take out cream if in a pot, or use a gloved finger and discard glove after). If transdermal patches (like pain or nicotine patches) are used, remove the old patch (dispose of it safely, folding it on itself), and apply the new one to a different appropriate area as instructed, recording site if required.
    • For eye/ear drops: ensure the dropper does not touch the eye/ear or any surface. Have the person tilt head appropriately. Drop the prescribed number of drops, and gently wipe excess with a clean tissue.
    • For insulin injections or other injections: these will only be done by care staff if explicitly agreed and trained for that task (delegated nursing task). If so, follow the detailed procedure taught (checking blood sugar if required, using sterile technique, correct injection site rotation, using sharps box for disposal, etc.). If not within our role, a nurse or the individual themselves would handle injections.
  6. Confirmation and Comfort: After giving the medicine, confirm with the person that they have taken it and are feeling okay. E.g., “Did those tablets go down alright? Would you like another sip of water?” or “Let me know if you feel any discomfort after that inhaler dose.” This also gives a moment to observe if any immediate reaction or coughing, etc.
  7. Documentation (Record Keeping): Immediately record the administration on the MAR chart/eMAR. This includes marking the correct box for the date/time with initials (or per eMAR, selecting the medication and recording it given). Never sign for a medication before it is given – always after you have witnessed it being taken. If a dose was scheduled but not given, do not leave the MAR blank; instead, note the appropriate code or note for why (e.g., “R” for refused, “O” for out of stock, or a written explanation if needed such as “withheld due to low blood pressure – GP instructed”). For PRN (as-needed) medications, record the exact time given and reason (like “Paracetamol 500mg – given at 2pm for headache rated 6/10”). If using eMAR, ensure you sync or save the data so that it’s updated in the system. Accurate record keeping is crucial for continuity and is a legal document of the care provided.
  8. Observation: Continue to observe the person for a short time after administration for any immediate adverse effects, especially if it’s a new medication or a high-risk one (like opioids or insulin). If the care worker is only there for a brief visit, they should use their judgment – e.g., if giving a strong pain medication or insulin, try to stay for 15-20 minutes if possible to ensure no acute reaction occurs, or have a protocol to call and check in later if needed. Any concerns, contact a healthcare professional as appropriate.
  9. Cleanup: Dispose of any used supplies (packaging, gloves, medicine cup washed). Ensure medicines are put back in their proper storage location securely. Maintain a clean environment (e.g., wipe any spills).

“As Needed” (PRN) Medications: PRN medications are those given only when required, based on certain criteria (such as pain, anxiety, high temperature, etc.). The care plan will specify for each PRN medication:

When administering a PRN:

Time-Sensitive Medications: Some medications have strict timing requirements (e.g., medications for Parkinson’s disease that must be on time to prevent symptom flare, or antibiotics that need evenly spaced dosing). If the care plan indicates a medicine is time-critical, {{org_field_name}} will ensure the visit scheduling accommodates this. Care workers must prioritize giving that medication at the exact time prescribed (within an acceptable window, usually 30 minutes before/after for most meds, but for Parkinson’s often exactly on time is vital). If a visit is delayed for any reason, and a time-critical dose will be late, staff should inform the office so that alternative arrangements (like an urgent replacement carer or asking a family member to cover) can be made to avoid a missed or significantly late dose.

Administration of Controlled Drugs: As mentioned in storage, controlled drugs require careful handling:

Refusal of Medication: Individuals have the right to decline medication. If a service user refuses a medication:

Covert Administration: Covert administration means giving a medication disguised in food or drink without the person’s knowledge. This is only considered in situations where:

Covert medication must be done in line with best practice and legal requirements:

By following this careful process, we ensure covert administration is only used ethically and safely. This is in line with CIW guidance that any covert medication must follow current best practice guidelines (which include adhering to the Mental Capacity Act and NICE guidance).

Non-Prescribed Medications (OTC and Herbal Remedies): Service users may sometimes want to take over-the-counter (OTC) products or herbal supplements (like paracetamol for a headache, herbal sleep aids, vitamins, etc.). The policy of {{org_field_name}} is:

After Administration – Monitoring and Follow-up: Administration doesn’t end with signing the MAR. Staff should remain vigilant after giving medicines:

To ensure consistency and safety, {{org_field_name}} will provide a Medication Administration Record (MAR) for each service user, or use an electronic MAR system, where every dose administered (or support provided) is recorded. This is a critical tool for communication among different staff visiting the person and also serves as evidence of care provided. As recommended by NICE, all medicine support provided must be recorded on a medicines chart, including instances of assistance or prompting. Robust documentation and following of these procedures ensures that medication administration is safe, person-centred, and in line with regulatory standards.

 

Self-Administration and Assistive Technology

Supporting Self-Administration: {{org_field_name}} recognizes the importance of enabling individuals to manage their own medications wherever feasible. Self-administration means the person takes responsibility for taking their medication themselves, with minimal or no help. Many service users, even if they need help with other aspects of care, may be perfectly capable of handling their medicines, or can do so with just a bit of support (such as reminders or help opening bottles). The benefits of self-administration include promoting independence, giving the person greater control and privacy, and maintaining their skills which is empowering and can improve confidence.

During the initial assessment (and ongoing reviews), we determine if the individual can self-administer safely and what support, if any, they need to do so. If a person is assessed as able to self-administer:

Assistive Devices and Technology: There are many tools and technologies available that can help individuals manage their medicines more independently or help staff manage medicines more safely. {{org_field_name}} will consider and use these assistive solutions as appropriate:

Balancing Support and Autonomy: When using assistive tech or devices, the approach is always to support the person’s independence, not to impose complicated gadgets they don’t want. Training and familiarization are key – both for the individual (if they are to interact with the device) and for staff (who need to know how to set it up or troubleshoot basic issues). For example, if we introduce an automated dispenser, we’ll ensure staff (and the person) know how to respond if it beeps and they’re not sure what to do, or how to pause it if the person goes to the hospital (so it doesn’t keep dispensing at home uselessly).

Reviewing Self-Administration: If a person is self-medicating, we will regularly review that arrangement to ensure it remains safe. For instance, if over time the person’s memory declines and they start forgetting doses or making mistakes, we will adjust the plan to increase staff support. Conversely, if a person has regained capacity or confidence to do more on their own, we’ll happily step back accordingly. All changes should be agreed with the person (and possibly family/health professionals). The guiding principle is the least intrusive support necessary: enough help to keep them safe and healthy, but not so much that it undermines their independence.

Documentation for Self-Administration: Even if staff are not administering, it is important the care plan notes that the person is managing their own medication. Staff should document in visit notes that they prompted or observed medication taken if that’s part of their duties. If fully independent, staff might simply note “Client self-medicating – no issues observed” periodically. This creates a record in case any concerns later (we can show we were monitoring as agreed). If the person uses an eMAR themselves (some tech-savvy clients or family might log doses), we can incorporate that data or at least be aware of it.

In essence, {{org_field_name}} will always consider and implement ways for a service user to safely self-administer through risk assessment, clever use of technology, and periodic oversight. This approach aligns with NICE and national guidance stressing that people should be supported to manage their own medicines as much as they are able. The dignity and independence of the individual are at the forefront of our medication support model.

Use of eMAR and Documentation Protocols

Accurate documentation of medication support is not only a legal requirement but also a crucial part of safe care delivery. {{org_field_name}} utilizes a Medication Administration Record (MAR) system for every service user receiving medication support. We are progressively using an electronic MAR (eMAR) system to enhance accuracy and real-time monitoring, though in some cases paper MAR charts may still be in use. This section outlines how staff must use these tools and maintain records, in line with both regulatory standards and good practice.

Medication Administration Record (MAR): The MAR is the official record of all medications administered, prompted, or refused. For each individual, the MAR includes:

Staff must follow these MAR documentation rules:

Electronic MAR (eMAR): Our eMAR system (specific software name, if any, can be mentioned in actual policy) is used via secure mobile devices by staff. Key protocols for using eMAR:

Other Documentation:

Proper record-keeping is essential not only for continuity of care (so that each staff member knows what has been done or needs doing) but also for demonstrating compliance. CIW inspectors will expect to see that our medication records are complete, up-to-date, and in accordance with this policy and regulatory standards. Indeed, maintaining clear and accurate medication records is a professional requirement under the Social Care Wales Code. It is also part of the governance arrangements recommended by NICE for managing medicines safely.

In summary, whether using paper charts or eMAR, {{org_field_name}} staff must treat documentation as an integral part of the medication process. “Not documented, not done” is a useful adage – if a medication support action isn’t recorded, we consider that it hasn’t legally been done. Therefore, all staff are trained and expected to complete records diligently, ensuring that at any time, an accurate picture of the individual’s medication intake is available.

 

Error Prevention and Incident Reporting

Despite best efforts, mistakes or adverse incidents can occur in medication management. {{org_field_name}} is committed to minimizing medication errors through proactive prevention strategies and to transparent, effective handling of any incidents that do happen. This section describes how we prevent errors and how we respond if an error or “near miss” is identified, including our incident reporting procedures. It aligns with regulatory expectations that providers have arrangements to prevent unsafe practices and to learn from mistakes as part of continuous improvement.

Strategies for Error Prevention:

Recognizing a Medication Error: A medication error is any deviation from the prescribed medication regimen, which can include:

A “near miss” is when an error almost happened but was caught just in time (e.g., staff prepared the wrong tablet but realized before the person took it).

Immediate Actions if an Error Occurs:

  1. Ensure Safety of the Individual: This is top priority. As soon as an error is realized, the staff’s first step is to assess if any harm could come or is coming to the person. For example, if a dose was missed, what is the risk? If a double dose was given, could that cause an overdose effect? If the wrong medicine was given, what are the potential side effects?
    • Depending on the situation, the staff may need to seek medical advice immediately. Often the instruction is to call the GP or NHS 111 (or 999 if potentially life-threatening) and explain exactly what happened to get professional advice on what to do. For instance, in overdose cases, they might instruct to monitor vitals, induce vomiting, or go to hospital.
    • Do not attempt any drastic measures without professional guidance (like giving another drug to counteract, etc., unless it’s something like using a glucometer for suspected insulin overdose which is within skills).
    • If the person is at immediate risk (say they already show symptoms like difficulty breathing or severe allergic reaction), call emergency services (999) without delay.
    • Stay with the person, keep them as comfortable as possible, and observe for any changes.
  2. Inform the Person (Duty of Candour): If the individual is conscious and alert, explain in a straightforward, truthful manner what happened, and that you are taking steps to ensure their safety. Apologize for the mistake. For example, “I’m sorry, I made an error – I just realized I gave you your evening tablet twice. I have called the GP to ask what we should do. Are you feeling okay right now?” Being honest and not concealing information is part of our ethical duty. If the person lacks capacity, inform their representative or next of kin as appropriate.
  3. Contact a Supervisor/Manager: As soon as the immediate safety steps are underway, the care worker must inform their line manager or the on-call supervisor about the error. This should be done urgently (a phone call, not just leaving a message). The manager can provide support, help make decisions (like contacting the GP if not already done), and begin the incident management process. Management will also consider if the error is of a nature that requires notifying external authorities (see below).
  4. Follow Medical Advice: Based on the guidance from GP/111/999, implement the recommended actions – that could be giving food (for a missed meal with insulin scenario), not giving the next dose, or going to hospital, etc. Ensure these instructions are clearly understood and passed on if another staff or family will be with the person later (for example, “GP said to skip the next dose and resume tomorrow, I have written this in the care notes and informed the daughter”).
  5. Monitoring After Error: Keep a close eye on the individual for any delayed effects, as some medication issues might not be immediate. If the care worker’s visit is over, they must ensure someone is monitoring (either a family member informed to observe, or maybe extend the visit duration, or arrange a follow-up call). Never just leave a person alone after a serious medication error without a plan for observation.

Incident Reporting Procedures:

Near Misses: We encourage reporting of near misses with equal importance as actual errors. A near miss (like catching that you almost gave the wrong tablet but realized in time) is a free lesson – no one was harmed, but there was a vulnerability in the system. Staff should document near misses in an incident form as well, and these will be reviewed to improve safety. We commend staff for honesty in these cases, reinforcing that it’s about fixing issues, not punishing.

Auditing and Continuous Improvement: All medication incidents and errors are logged in an incident register. The Registered Manager or a delegated quality officer will review these logs periodically (at least quarterly) to identify any patterns – e.g., multiple errors happening at a certain time of day or with a certain drug or by certain staff. This analysis helps target improvements (like extra training sessions, or if many errors involve one pharmacy’s labeling maybe communicate with that pharmacy). It’s also a measure of our performance: our goal is to minimize medication errors, so we track our error rate and aim for continuous reduction.

Finally, throughout the error management process, we adhere to the principles of candour, accountability, and learning. We make sure the individual (and family) receive a genuine apology and explanation as appropriate, which is their right. Staff involved reflect on the incident with support – perhaps writing a reflection or discussing in supervision to consolidate learning. And any systemic fixes are implemented to prevent recurrence. CIW expects providers to have this responsive approach to medication errors, and to see that lessons are actually leading to safer practice. {{org_field_name}} is dedicated to doing exactly that: preventing what we can, and when something does go wrong, responding professionally and improving for the future.

 

Disposal of Medication

Proper disposal of medications is essential to prevent environmental contamination, misuse, or accidental ingestion by others. {{org_field_name}} has procedures to ensure that unused or expired medicines are disposed of safely and in line with legal requirements and guidance. The arrangements for disposal are also a required component of our medicines management system under Regulation 58.

When Medication Disposal is Needed:

Procedure for Disposal in Domiciliary Care:

Environmental Considerations: Welsh Government environmental guidance (and NHS directives) advise against flushing medications down toilets or sinks because of the impact on water systems. By returning meds to pharmacies or using proper waste channels, we ensure we’re also following these eco-friendly practices. Commissioners and providers are encouraged to reduce environmental impact of medication waste, for example by not over-ordering medicines. {{org_field_name}} contributes by checking with service users that only needed medications are ordered (no automatic reordering of everything if not needed) and thus minimizing surplus to dispose.

When Service Users Leave the Service: If a service user is permanently discharged from our care (e.g., moves to a care home or service ends), we will make sure any medications in their home are either transferred with them (with a detailed list handed over to the next care provider or hospital) or disposed of if not needed. We don’t leave medication sitting without clear responsibility.

By following these disposal protocols, we maintain safety (no leftover meds for someone to accidentally take), regulatory compliance (Regulation 58’s requirement for proper handling and disposal), and environmental responsibility. Care staff will be trained on these procedures and know that disposal is as important as administration in the medication management cycle.

 

Governance, Training, Audit, and Continuous Improvement

Robust governance and a commitment to continual improvement are essential to maintaining high standards in medication management. {{org_field_name}} ensures that there are clear lines of accountability, that staff are well-trained and competent, and that our medication practices are regularly audited and refined. This section details the structures and processes in place for oversight, training, quality assurance, and policy review.

Roles and Responsibilities:

Training and Competency:

Audit and Quality Assurance:

Continuous Improvement:

Documentation and Communication in Governance: All these governance activities (training records, audit reports, policy updates, incident analyses) are documented. There is a clear audit trail showing compliance with Reg 58’s expectation of systems for oversight. Furthermore, CIW during inspections will ask how we ensure safe medicines management – our answer is through this multi-layered governance approach of competent staff, rigorous audits, and an open learning culture.

Conclusion: Through strong governance, comprehensive training, diligent auditing, and a commitment to learning, {{org_field_name}} strives to maintain the highest standards of medication management. This not only ensures compliance with CIW regulations and standards, but more importantly, it ensures the people we support receive their medication safely, effectively, and in a manner that enhances their well-being. Our organization’s leadership regularly evaluates this area of care and provides the necessary support and resources to continuously improve our medication management practice.

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

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