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Medication Management and Administration Policy

1. Introduction

Purpose of the Policy

At {{org_field_name}}, we are committed to ensuring that all individuals receiving care in their own homes are supported to manage and take their medication safely, effectively, and in a way that upholds their dignity, independence, and personal preferences. This policy sets out clear procedures for the safe administration, recording, and handling of medication by our care staff, in line with Scottish legal and regulatory requirements.

Our primary aim is to:

• Protect the health, safety, and well-being of individuals who receive medication support.
• Ensure that care staff are trained, competent, and confident in medication management.
• Promote self-management and independence where possible.
• Comply with legal, regulatory, and best practice guidance to maintain the highest standards of care.
• Provide a clear framework for staff, service users, and families regarding roles and responsibilities in medication management.

Legal and Regulatory Framework

This policy aligns with Scottish national standards, laws, and best practices, ensuring that our service is safe, person-centred, and accountable. We follow:

• Health and Social Care Standards (Scotland)
  • These standards set out what individuals should expect from our care service. We ensure that:
    • People experience high-quality care and support that is right for them.
    • Medication is managed safely and effectively.
    • Service users are involved in decisions about their medication wherever possible.
• National Care Standards: Care at Home
  • Standard 8: Keeping Well – Medication ensures that individuals receiving support at home:
    • Are encouraged to manage their own medication where possible.
    • Receive support from staff who follow best practice and have the necessary training.
    • Have clear records of medication stored and administered safely.
• Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011
  • Regulation 4: Ensures that providers make proper arrangements for the health, welfare, and safety of service users, including medication management.
  • Regulation 5: Requires that each person receiving care has a detailed personal plan, including medication needs and administration details.
• SSSC Codes of Practice for Social Service Workers and Employers (2024)
  • Our staff are expected to:
    • Work in a way that protects individuals from harm.
    • Follow policies and procedures for safe medication administration.
    • Maintain clear, accurate records.
    • Report concerns, errors, or risks immediately.

Scope of the Policy

This policy applies to:

• All care staff involved in medication support, including prompting, assisting, or administering medication.
• Service users who require medication support, whether occasional or ongoing.
• Family members and representatives involved in the individual’s care and medication decisions.

2. Principles of Safe Medication Management

We are committed to ensuring that medication management is conducted in a way that prioritises safety, dignity, and personal choice. Our approach is person-centred, rights-based, and compliant with Scottish legal and regulatory requirements. We expect all staff to uphold these principles in every aspect of medication support.

Person-Centred Approach

We recognise that every individual is unique, with personal preferences and needs regarding their medication. Our person-centred approach ensures that:

• Each service user’s medication support is tailored to their specific requirements, preferences, and abilities.
• Wherever possible, we promote self-management of medication to maintain independence.
• Care plans are developed in partnership with service users, their families, and healthcare professionals to ensure the best outcomes.
• Medication support is regularly reviewed to reflect changes in health, lifestyle, or preferences.

Rights-Based Care: Supporting Independence, Choice, and Dignity

Our care approach is rooted in human rights and dignity, ensuring that:

• Individuals have the right to make informed choices about their medication, including the option to refuse.
• We support individuals to understand their medication, its purpose, and any potential side effects.
• Medication management is provided discreetly and respectfully, preserving privacy and personal dignity.
• We respect cultural, religious, and personal beliefs regarding medication and involve service users in decision-making.

Compliance with Laws and Best Practices

We adhere to all Scottish legal requirements, regulatory standards, and best practices to ensure safe and effective medication management. Our service complies with:

• Health and Social Care Standards (Scotland) – Ensuring medication support is safe, effective, and aligned with personal needs.
• National Care Standards: Care at Home – Maintaining best practices for safe storage, administration, and record-keeping.
• Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 – Ensuring medication support meets the highest safety standards.
• SSSC Codes of Practice for Social Service Workers and Employers – Holding our staff accountable for professional and ethical conduct in medication management.

Accountability and Staff Training

We ensure that all staff are fully trained and accountable for medication management by:

• Providing mandatory medication training before any staff member administers medication.
• Conducting ongoing competency assessments to ensure staff follow the correct procedures.
• Maintaining clear records of all medication administered, refused, or altered.
• Requiring staff to immediately report any medication errors or concerns so they can be addressed promptly.
• Encouraging a culture of learning and improvement, where staff can seek guidance and further training to enhance their skills.

3. Roles and Responsibilities

At {{org_field_name}}, we ensure that everyone involved in medication management understands their role and responsibilities. By clearly defining these expectations, we promote safe, effective, and person-centred medication support.

3.1 Care Staff

Our care staff play a vital role in supporting individuals with their medication needs. We expect all care staff to:

• Administer medication only if trained and assessed as competent – No staff member is permitted to administer medication unless they have completed mandatory medication training and been formally assessed as competent.
• Follow individual care plans and Medication Administration Records (MAR) – Staff must always refer to up-to-date care plans and accurately complete MAR charts to document medication administration.
• Report errors or concerns immediately – If a medication error occurs, or if there are concerns about a service user’s medication (e.g., side effects, refusal, incorrect dosage), staff must report it immediately to management for prompt action.
• Encourage independence – Where appropriate, staff should support service users in managing their own medication safely, promoting their confidence and autonomy.

3.2 Management

The management team at {{org_field_name}} is responsible for ensuring that medication support meets regulatory standards and best practices. Our management responsibilities include:

• Ensuring staff receive appropriate medication training – We provide comprehensive, ongoing training to all care staff involved in medication administration. Staff competency is regularly reviewed to maintain high standards.
• Maintaining quality assurance and audit processes – We conduct regular audits of MAR charts, care plans, and incident reports to identify any areas for improvement and ensure compliance with regulations.
• Investigating medication errors and taking corrective action – In the event of a medication error or near-miss, we immediately review the incident, identify causes, and implement corrective measures. This may include additional training, policy updates, or procedural changes to prevent future occurrences.
• Ensuring compliance with legislation – Management ensures that all medication practices align with the Health and Social Care Standards, National Care Standards, SSSC Codes of Practice, and regulatory requirements.

3.3 Service Users and Families

We believe in empowering service users and their families to take an active role in medication management where possible. Their responsibilities include:

• Encouraging self-management of medication where safe – If a service user is capable and wishes to manage their own medication, we support them with clear guidance, reminders, and practical assistance where necessary.
• Providing clear consent for staff involvement in medication administration – Before our staff can assist with medication, service users (or their legal representatives) must provide explicit, informed consent. This ensures that our role in medication support aligns with the individual’s wishes, rights, and best interests.
• Communicating changes in medication – Families and service users must inform us immediately if there are any changes to prescriptions, dosages, or medication routines, so that care plans and MAR charts can be updated accordingly.

4. Medication Administration Procedures

At {{org_field_name}}, we ensure that medication is administered safely, accurately, and in line with best practice guidance. Our procedures follow a tiered support system to meet individual needs, maintain clear records, and uphold the highest standards of medication handling.

4.1 Levels of Support

We offer different levels of support based on the needs and capabilities of each service user:

• Level 1: Prompting and Reminding Only
  • The service user is fully responsible for taking their medication.
  • Staff provide verbal prompts or reminders but do not physically assist.
  • This level is appropriate for individuals who can manage their medication but need occasional reminders.
• Level 2: Assistance with Administration
  • Staff help with preparing medication (e.g., opening bottles, removing tablets from blister packs).
  • Service users remain in control of their medication, with staff providing only practical support.
  • Staff must not place medication directly into the service user’s mouth but can hand it to them.
• Level 3: Full Administration by Trained Staff
  • When a service user cannot safely self-administer, trained staff directly administer the medication.
  • Staff must have completed competency-based medication training before administering medication.
  • This includes supporting individuals who may lack capacity or require specialised medication administration (e.g., insulin injections under NHS guidance).

The level of support required is clearly documented in the service user’s care plan and regularly reviewed.

4.2 Medication Record Keeping

To maintain accountability and safety, we use a Medication Administration Record (MAR) chart for all medication support. Staff must:

• Use MAR charts consistently – Every medication administered, assisted, or refused must be recorded.
• Maintain clear, up-to-date records – Information should be accurate, legible, and aligned with the service user’s current prescription.
• Document missed doses, errors, or refusals – If a service user refuses medication, this must be recorded, and concerns should be escalated if refusals become frequent.
• Report medication changes – Any modifications to medication (e.g., dosage adjustments) must be documented immediately, and the care plan updated accordingly.

4.3 Storage and Handling

Proper medication storage and handling are essential for safety and effectiveness. Our procedures ensure:

• Safe storage within the service user’s home
  • Medication should be stored in a designated, clean, dry, and secure area.
  • Any refrigerated medication should be kept at the correct temperature and labelled appropriately.
• Controlled drugs are appropriately managed
  • Controlled drugs (CDs) are stored securely, following legal and regulatory requirements.
  • Administration of CDs must be recorded in both the MAR chart and a separate Controlled Drug Register.
• Infection control measures are followed
  • Staff must wash hands before and after handling medication.
  • Any spills, expired medication, or contamination risks must be reported immediately.

4.4 Administration Methods

We ensure that care staff only administer medication via approved methods, following best practices for:

• Oral medication – Tablets, capsules, and liquid medicines must be given according to prescription instructions (e.g., with/without food, at specific times).
• Topical applications – Creams, ointments, and patches should be applied using gloves, ensuring proper hygiene and dosage accuracy.
• Inhalers and nebulisers – Staff support individuals to use these correctly, ensuring devices are clean and well-maintained.
• Eye/ear drops – Drops should be administered following infection control procedures, ensuring correct positioning and dosage.
• Controlled drugs – Staff handling controlled drugs must be trained in additional safety protocols, including double-checking dosages and recording administration in a CD register.

5. Medication Errors and Incident Reporting

We take medication errors very seriously and have clear procedures in place to ensure that any mistakes are reported, investigated, and used as learning opportunities to prevent recurrence. Our goal is to provide safe, accountable, and high-quality medication support while minimising risk to service users.

Definition of Medication Errors

A medication error is any mistake made in the prescribing, dispensing, administering, storing, or recording of medication. This includes:

• Wrong medication given – Administering a medication that was not prescribed for the service user.
• Incorrect dosage – Giving too much or too little of a prescribed medication.
• Missed or delayed doses – Failing to administer a medication at the prescribed time.
• Incorrect method of administration – For example, giving medication orally when it was prescribed to be given topically.
• Failure to document administration correctly – Including not recording a medication given, or making an incorrect entry in the Medication Administration Record (MAR) chart.
• Failure to recognise and report adverse reactions – Any side effects, allergies, or unexpected symptoms must be documented and escalated immediately.

Reporting Procedures

All medication errors, no matter how minor, must be reported immediately to ensure service user safety and maintain regulatory compliance. The following steps must be taken:

1. Immediate Response
   • If a service user has been given an incorrect dose or medication, assess for any adverse effects.
   • Seek medical advice from a GP, pharmacist, or NHS 24 if necessary.
   • Inform the service user and their family/representative, ensuring transparency.
2. Documenting the Error
   • Record the error in the MAR chart and any additional incident reporting system.
   • Include full details: what happened, what action was taken, and any outcomes.
   • If the medication was missed or refused, this must also be clearly documented and reported if there is a risk to the service user’s health.
3. Internal Investigation
   • Management will conduct a formal review of the incident to determine the cause of the error.
   • Staff involved must provide a written account of the incident.
   • Any patterns or recurring issues will be identified to prevent further errors.

Actions Following an Error

After a medication error, we focus on learning, improvement, and prevention to ensure staff confidence and service user safety.

• Reflection and Discussion
  • Staff involved in the error will be asked to reflect on what happened and discuss ways to prevent similar incidents.
  • Open discussion encourages a culture of learning, not blame.
• Retraining and Competency Checks
  • If an error occurred due to lack of knowledge or misunderstanding, the staff member will receive additional training.
  • A competency assessment may be required before they resume medication administration duties.
• Process Improvement
  • If the error was due to unclear procedures, communication failures, or system issues, we will review and improve our policies accordingly.
  • Changes may include additional training, clearer documentation procedures, or improved supervision.

6. Consent and Capacity

At {{org_field_name}}, we respect every individual’s right to make informed decisions about their medication. Where a service user lacks the capacity to consent, we follow legal frameworks and best practices to ensure that decisions about medication are made in their best interests, with appropriate safeguards in place.

Adhering to the Adults with Incapacity (Scotland) Act 2000

The Adults with Incapacity (Scotland) Act 2000 provides a legal framework for supporting adults who lack the capacity to make their own decisions due to conditions such as dementia, brain injury, or learning disabilities. Our approach ensures that:

• Every service user is assumed to have capacity unless formally assessed otherwise.
• We support individuals to understand their medication, using clear communication, visual aids, and other accessible methods where needed.
• If a service user is unable to give informed consent, we work in line with the Act to ensure that medication decisions are made lawfully and in their best interests.
• We consult with medical professionals, legal representatives, and family members to ensure that decisions are ethically and legally sound.

Role of Power of Attorney or Legal Guardian

When a service user is unable to make decisions about their medication, a Power of Attorney (POA) or legal guardian may be appointed to act on their behalf. In these cases, we:

• Confirm and document who has the legal authority to make decisions about medication.
• Consult the POA or guardian before making any changes to prescribed medication.
• Ensure that medication administration aligns with the individual’s best interests and prior wishes where known.
• Work closely with healthcare professionals and families to ensure that decisions are safe, appropriate, and legally compliant.

We require legal documentation (e.g., guardianship orders, POA certificates) to be provided and stored in the service user’s care plan for clarity and accountability.

Use of Covert Medication

Covert medication (administering medication without the service user’s knowledge, such as mixing it with food or drink) can only be used in exceptional circumstances and must follow strict legal and ethical guidelines. Our policy ensures that:

• Covert medication is a last resort and only considered when a service user repeatedly refuses essential medication, posing a significant risk to their health.
• A multidisciplinary team (MDT) decision is required – This includes a GP, pharmacist, care staff, legal representatives (POA/guardian), and family members where appropriate.
• A formal covert medication care plan is developed, clearly documenting:
  • The reason for covert administration.
  • The specific medications involved.
  • How and when the medication will be given.
  • Regular reviews to assess if covert administration is still necessary.
• Legal and ethical safeguards are maintained – Decisions must be in line with the Adults with Incapacity (Scotland) Act 2000 and the Mental Welfare Commission Scotland’s guidelines on covert medication.

All covert medication plans must be documented, regularly reviewed, and subject to oversight by healthcare professionals to ensure ongoing compliance and ethical integrity.

7. Training and Competency Assessment

We recognise that safe and effective medication management relies on well-trained, competent, and confident staff. We are committed to providing comprehensive training, ongoing competency assessments, and regular refresher courses to ensure that all medication administration follows best practice and regulatory standards.

Mandatory Medication Training for All Staff

All staff involved in prompting, assisting, or administering medication must complete mandatory medication training before undertaking any medication-related tasks. This training covers:

• Legal and regulatory requirements, including the Health and Social Care Standards (Scotland), National Care Standards, and SSSC Codes of Practice.
• The principles of safe medication administration, including understanding different types of medication, correct administration techniques, and dosage calculations.
• The use of Medication Administration Records (MAR) charts for accurate documentation.
• Recognising and responding to medication errors and adverse reactions.
• Person-centred medication support, ensuring individuals retain as much independence as possible in managing their medication.
• Infection control procedures to ensure safe handling and administration of medication.

Staff must successfully complete this training and demonstrate competency before they are authorised to administer medication.

Regular Competency Checks and Refresher Training

To maintain high standards of medication safety, we conduct:

• Initial competency assessments – After training, all staff undergo practical competency checks to ensure they can administer medication safely and correctly.
• Ongoing competency assessments – Staff must demonstrate continued competency through observations, assessments, and spot checks conducted by senior staff or management.
• Annual refresher training – All staff must complete refresher courses to update their knowledge and skills, reinforcing best practices and addressing any areas for improvement.
• Additional training following errors – If a staff member is involved in a medication error, they may be required to undergo targeted retraining to prevent recurrence.

We take a proactive approach to staff development, ensuring all team members feel confident and well-equipped to handle medication safely and effectively.

Keeping Up with Best Practice Updates

Medication management is constantly evolving, with new best practices, guidelines, and regulations emerging over time. We ensure that:

• Staff receive ongoing updates on new legislation and policy changes that affect medication administration.
• Best practices from organisations such as the Care Inspectorate, NHS Scotland, and the Royal Pharmaceutical Society are integrated into training and policies.
• Regular team meetings and supervision sessions include discussions on medication safety, new guidance, and lessons learned from previous incidents.
• Staff have access to continuous professional development (CPD) opportunities, including additional training courses and external workshops.

8. Quality Assurance and Auditing

We are committed to maintaining the highest standards of medication management through a robust quality assurance and auditing system. Our approach ensures that medication administration is safe, effective, and continuously improving, in line with regulatory requirements and best practices.

Routine Medication Audits

Regular audits help us identify potential risks, ensure compliance, and improve our medication management processes. We conduct:

• Weekly MAR chart checks – Senior staff review Medication Administration Records (MAR) to ensure they are accurate, complete, and up to date.
• Monthly medication audits – Management conducts in-depth reviews of medication administration, focusing on storage, documentation, and adherence to procedures.
• Controlled drugs audits – Where applicable, we carry out additional checks for controlled drugs to ensure they are handled, recorded, and stored correctly, in compliance with legislation.
• Random spot checks – Unscheduled audits ensure that staff are consistently following correct procedures and maintaining high standards of care.

Findings from these audits are documented, and any discrepancies or areas for improvement are addressed immediately through retraining or process adjustments.

Reviewing Policies Annually or as Needed

To ensure that our medication management remains up to date and effective, we:

• Review medication policies annually to align with the latest guidance from:
  • The Care Inspectorate
  • Health and Social Care Standards (Scotland)
  • The National Care Standards: Care at Home
  • The SSSC Codes of Practice
• Update policies as needed in response to changes in legislation, regulatory guidance, or best practice recommendations.
• Consult staff and stakeholders when making significant policy changes to ensure that updates reflect practical and operational realities.
• Ensure all staff are informed and trained on any policy changes, with documented confirmation of their understanding.

This proactive approach ensures that our policies remain current, effective, and fully compliant with all legal and professional requirements.

Learning from Incidents and Feedback

At {{org_field_name}}, we believe that continuous improvement is key to providing safe and effective medication support. We foster a learning culture, ensuring that incidents and feedback drive meaningful improvements.

• Medication incident reviews – Whenever a medication error or near-miss occurs, we conduct a thorough investigation to determine the cause and implement corrective actions.
• Staff reflection and learning – Staff involved in incidents are encouraged to reflect on what went wrong and how to prevent future occurrences. Where necessary, additional training and support are provided.
• Feedback from service users and families – We actively seek input from those receiving care to understand their experiences, identify concerns, and improve our medication processes.
• Staff supervision and debriefing – Managers hold regular one-to-one meetings with care staff to discuss challenges, concerns, and opportunities for improvement in medication management.

By embedding routine audits, policy reviews, and a culture of learning, we ensure that medication management at {{org_field_name}} remains safe, effective, and continuously improving.

9. Review and Updates

To maintain high standards and compliance, we:

• Review this policy annually to ensure it aligns with the latest Health and Social Care Standards, National Care Standards, and SSSC Codes of Practice.
• Conduct interim reviews if there are significant legislative changes, emerging risks, or concerns identified through audits or incident reporting.
• Seek feedback from staff, service users, and families to assess whether the policy remains effective, practical, and relevant to daily care delivery.
• Document all policy changes and ensure that any updates are clearly communicated to all staff and stakeholders.

All staff must confirm that they have read and understood any policy revisions to ensure full implementation.

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Responsible Person: {{org_field_registered_manager_first_name}}{{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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