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Medication Management and Administration Policy (Domiciliary Care – Scotland)

Relevant Legislation and Current Best Practice Guidance

This Medication Management and Administration Policy is fully aligned with current legislation, statutory guidance, professional standards and best practice recommendations applicable to domiciliary care services in Scotland. It incorporates:

Key Legislation

• The Medicines Act 1968 – the primary legislation regulating the manufacture, supply, prescribing, dispensing and administration of medicines within the UK.
• Misuse of Drugs Act 1971 & Misuse of Drugs Regulations 2001 (as amended for Scotland) – governing controlled drugs (Schedule 1-5 substances), storage, administration, documentation and disposal.
• The Health and Social Care Standards: My Support, My Life (2017) – particularly Standards 2.23, 3.14, 4.11, and 4.19 which promote safe, person-centred medication management, ensuring people maintain control where possible and receive support from trained, competent staff.
• The Regulation of Care (Scotland) Act 2001 and Public Services Reform (Scotland) Act 2010 – underpinning Care Inspectorate regulatory responsibilities.
• Social Care and Social Work Improvement Scotland (Requirements for Care Services) Regulations 2011 (SSI 2011/210) – legally requiring care services to ensure the health, welfare and safety of people who use services.
• Health and Care (Staffing) (Scotland) Act 2019 – placing duties on providers to ensure appropriate staffing levels, competence, supervision, and safe care, including safe medication practices.
• The Adults with Incapacity (Scotland) Act 2000 – governing consent to treatment and administration of medication for people lacking capacity.
• The Equality Act 2010 – ensuring equitable access to safe medication support free from discrimination.
• The Data Protection Act 2018 / UK GDPR – regulating confidentiality and security of service user medication records.

Professional Standards and Best Practice Guidance

• Scottish Social Services Council (SSSC) Codes of Practice (2024) – outlining employer and employee duties to promote safe practice, competence, clear record keeping, ongoing learning and accountability in medication management.
• Care Inspectorate: Guidance about medication personal plans, review, monitoring and record-keeping in residential care services (2021) – principles equally applicable to care at home settings, detailing expectations for risk assessment, care planning, administration, review and record keeping.
• Royal Pharmaceutical Society (RPS): The Handling of Medicines in Social Care (updated version 2019) – widely recognised professional best practice guidance for all social care providers handling medicines.
• NHS Scotland Best Practice Statements (where applicable) – relating to specific aspects of safe medication practice, such as PEG feeding, insulin administration and covert medication procedures.
• Scottish Government Framework for Supporting People with Complex Healthcare Needs (2017) – outlining safe delegation of healthcare tasks (e.g. PEG administration, insulin) to social care workers when appropriately trained and supervised.
• Care Inspectorate Duty of Candour Guidance – ensuring transparency and openness in the event of medication errors or harm.
• NICE Guidance – providing evidence-based guidance relevant to specific clinical areas or medication regimes.

1. Purpose and Scope

This policy outlines how our domiciliary care service in Scotland manages and supports medication for service users in their own homes. It is written in line with current Care Inspectorate guidance and Scottish Social Services Council (SSSC) standards as of 2024/2025. It applies to all care staff, managers, and responsible persons involved in the handling of medication. The goal is to ensure safe, effective, and person-centered medication support, complying with all legal and regulatory requirements. This policy covers: supporting self-administration, prompting, direct administration, use of electronic Medication Administration Records (eMAR), handling of controlled drugs and PEG medications, staff training, roles and responsibilities, error management, and quality assurance.

Regulatory Context: This policy reflects the Health and Social Care Standards: my support, my life (2018) and relevant Care Inspectorate guidance. Key principles from these standards include ensuring that if individuals need help with medication, they maintain as much control as possible (Health and Social Care Standard 2.23 and having confidence that staff are trained, competent, and skilled (Standard 3.14. We also adhere to the SSSC Codes of Practice (2024), which require social service workers and employers to maintain high standards of care, including safe medication management, accurate recording, and continuous improvement in practice.

2. Policy Statement

We are committed to supporting people to manage their own medications wherever possible and to administering medications safely when support is needed. Each person’s independence and preferences are respected, and self-medication is encouraged if assessed as safe. When assistance or administration is required, staff will follow strict procedures to ensure the right person receives the right medication, in the right dose, at the right time, by the right route, with the right documentation and right to refuse (often referred to as the “7 rights” of medication administration). All medication support will be delivered in a manner that upholds dignity, privacy, and choice, in line with human rights and person-centered care values.

We use evidence-based best practices and regularly update this policy to remain compliant with current guidance (HSCS 4.11). A culture of continuous improvement is fostered in our service (HSCS 4.19), with robust quality assurance processes to monitor medication management and learn from any incidents. The policy is written in accessible language so that care staff can easily understand their duties, and it will be made available to all staff during induction and through ongoing training refreshers.

3. Definitions and Levels of Support

Assessment of Capability: Each service user will have an initial and ongoing assessment to determine what level of help they need with medication. This is documented in their care plan (sometimes called a personal plan) and will note whether they self-medicate independently, require prompts or some assistance, or need full administration by staff. The assessment considers the person’s memory, understanding of their medicines, physical ability to handle medicines (opening bottles, etc.), and risk factors. The individual (and if appropriate, family or representatives) will be involved in this assessment. We recognise that a person’s ability may change over time, so we review support levels regularly and adjust the care plan accordingly.

• Self-Administration: If a person is assessed as able to manage their own medication, they will retain control. Staff involvement is minimal, though we may assist with tasks like collecting prescriptions or providing reminders if requested. Independence is supported and encouraged. A pharmacist or other healthcare professional may be consulted for tools to assist self-management (for example, easy-open packaging or reminder charts). Even when self-administering, the service will document in the care plan how this is managed, and staff will respect the person’s autonomy while ensuring safety (e.g., checking that medications are stored properly in the home).
• Prompting: Prompting means reminding the person to take their medication at the appropriate times and confirming if they have done so. The individual remains in control and can choose not to take the medicine or to take it later. Example: A care worker might say, “It’s 8am, time for your tablets. Have you taken them?” This gentle prompt helps those who are forgetful but otherwise able to self-administer the medication. Important: Staff prompting must know which medications are due and when, as inappropriate prompting can lead to overdoses (e.g., prompting all medications multiple times a day when they are only due once. Our electronic system will flag the scheduled times for prompts to avoid such errors. All prompts given are recorded in the eMAR as a “prompt” action. If the person takes the medication after being prompted, the staff should note that in the record (or the person may mark their own record if fully self-managing). If the person refuses or delays, staff will respect their decision but report it if there are health implications (see Section 9 on refusals and omissions).
• Assisting: Assisting refers to helping an individual with the physical tasks of taking medication while the person still controls their own medicines. This might include handing them the blister pack, opening bottles or packaging at their direction, reading labels aloud, or checking the time/dose for them. The person directs the process, and the care worker does not decide or measure out doses independently. Examples of assistance tasks: ordering repeat prescriptions, picking up medicines from the pharmacy, popping tablets out of a dosette box for the person at their request, or helping lift an inhaler to the person’s mouth if they cannot do it alone. With assistance, the person should know what each medicine is for and when to take it; the staff is just facilitating. These actions are also recorded in the eMAR (with an appropriate code or note indicating assistance). The key distinction is that the care worker is not choosing which medicines to take – they follow the person’s routine or request, and the individual is considered to be self-medicating with help. As with prompting, if any dose is not taken for any reason, this is recorded and reported appropriately.
• Administration: Administration means the care worker takes responsibility for selecting, giving, and recording medication doses because the person cannot do so themselves reliably. This involves the staff ensuring: the correct medication, at the correct time, in the correct way is given to the right person. In these cases, the care worker will physically administer the medicine (e.g., putting the tablet in the person’s hand or mouth, applying a patch or cream, measuring liquid medicine, or giving insulin via an insulin pen if trained and delegated). Administration also includes situations where the person might ask the staff to handle the medicine and the task requires some skill or judgement by the staff to ensure correctness. For example, if a person has cognitive impairment and cannot recognise their pills, staff administering must identify the pills and give them correctly. All administration is documented immediately on the MAR/eMAR, including any instances of refusal, vomiting after dose, etc. Because administering medicine carries greater responsibility, staff must be specifically trained and deemed competent before performing medication administration duties. We never expect untrained or unverified staff to administer medicines.

Note: The level of support a person requires may vary for different medications or over time. For instance, someone might self-administer an inhaler but need staff to administer tablets and a nurse to administer injections. The care plan will detail these distinctions per medication. Staff should always refer to the care plan and MAR chart for each individual to understand what support is needed for each medicine.

4. Roles and Responsibilities

Safe medication management is a team effort. This section defines the responsibilities of the provider, managers, and care staff in storing, administering, recording, and reviewing medication. All staff and management must also adhere to their professional codes (e.g., SSSC Codes of Practice) which stress accountability, maintaining skills, and safeguarding service users.

• Provider/Registered Service Owner: The service provider holds ultimate accountability for medication safety in the service. They must ensure that there are sufficient trained staff to meet service users’ medication support needs at all times. The provider approves this policy and any updates, allocating resources for staff training and electronic record systems. They also ensure that insurance and legal requirements for medication handling (including indemnity for staff) are in place. The provider should promote a culture where medication safety is prioritised and any issues can be openly reported (no blame culture, aligned with Duty of Candour).
• Registered Manager: The manager is responsible for implementing this policy day-to-day. Theclude organising staff training and assessing staff competency regularly, scheduling appropriate staffing for medication rounds, and supervising staff compliance. The manager (or a nior staff member, such as a Care Supervisor or Medication Lead) must conduct medication risk assessments for each new service user and oversee the development of the medication section of each personal plan. They ensure medication records (MARs) are maintained accurately and audited (see Section 11). If medication errors or incidents occur, the manager leads the investigation and reporting process (including notifications to Care Inspectorate if required – see Section 10). The manager also keeps up with best practice updates or changes in medication regulations and updates the policy and procedures accordingly, to remain in line with current guidance and standards (HSCS 4.11). The manager or designated responsible person will maintain a system for reviewing this policy (at least annually or after any significant change in regulation).
• Care Staff (Support Workers/Care Assistants): All care staff who handle medications must follow this policy and the procedures meticulously. They are responsible for safely storing medications in the individual’s home, administering or prompting as per the care plan, and keeping clear, accurate records of all medication support provided. Care staff must ensure they only perform tasks they are trained and authorised to do – for example, giving medications via a Percutaneous Endoscopic Gastrostomy (PEG) tube or administering controlled drugs, only if they have received the necessary training and delegation (see Section 8). Staff have a duty to double-check each medication against the MAR/eMAR before giving it – confirming the individual, medication name, dose, route, and time. If in any doubt (e.g., label unclear, pills look different, individual expresses concern), they must pause and seek advice (from a supervisor, pharmacist, or NHS24) before administering. After giving or assisting with medication, staff immediately document the outcome on the MAR (paper or electronic). If a dose is declined or missed, they record it and inform the manager as per procedures. Care staff should also monitor for any side effects or changes in the service user’s condition and report these. Maintaining confidentiality and respecting the person’s privacy during medication support is essential, as is a kind and patient approach. Furthermore, staff must adhere to the SSSC Code of Practice by taking responsibility for their own learning – if they are unfamiliar with a medication, they should inform their line manager. They are also to cooperate with audits and investigations, and concerns immediately (even if it’s their honesty is critical to safety).
• Care Worker Line Manager / Senior Carers: In some structures, a line manager or senior carer oversees a group of support workers. This person is responsible for tasks such as organizing staff rotas to ensure medication visits are covered, dealing with medication queries or issues that arise on a shift, and doing first-line checks of MAR charts. They may also conduct spot checks or competency observations of staff administering medications. If a care worker has a concern (for example, difficulty getting a person to take medicine, or noticing a stock discrepancy), the line manager will address it or escalate to the Registered Manager. They often help with coordinating prescription ordering and liaising with healthcare professionals (GP, pharmacist, community nurse) about medication changes or reviews. Essentially, they support both the Manager and the frontline staff in ensuring medication management runs smoothly day-to-day.
• Designated Medication Champion (if appointed): We may appoint a senior staff member as a Medication Champion, responsible for championing best practice in medication. They assist with training other staff, keeping up with new guidance, and leading quality improvement initiatives related to medication (such as updating our eMAR usage or running workshops on medication safety). They are a point of contact for complex medication questions and may conduct additional audits.
• External Health Professionals: While not staff of our service, it’s important to note the roles of others involved:
  • The GP (Doctor) prescribes medications and should review them at appropriate intervals. The GP or nurse will provide a medication administration sheet (prescription) and any special instructions (e.g., how to taper a dose).
  • The Pharmacist dispenses the medications, often providing MAR charts or labels with clear instructions. We rely on pharmacies to label multi-compartment compliance aids (dosette boxes) properly and to highlight any high-risk medicines. Pharmacists can also do medication use reviews, which we encourage annually.
  • District Nurses/Community Nurses: They may administer certain medications (like injections, insulin starts, or specialist tasks) that our staff are not permitted to do unless delegated. We maintain good communication with nursing services for those individuals who have both nursing input and home care support.
  • Service User and Family: The individual receiving care has the responsibility (to the extent of their ability) to inform us of any self-medication they take outside of our knowledge (like over-the-counter drugs) so we can note potential interactions. Family members or informal carers involved in the person’s life should communicate with our staff about any medication concerns they observe, and similarly our staff will keep them informed (with consent) of how medication is going. If family handle some medications while we handle others, clear arrangements must be documented to avoid doses being missed or duplicated.

Everyone involved is expected to work together collaboratively, with clear communication about medication changes, issues, or errors. Roles and responsibilities must be agreed and understood by all so nothing “falls through the cracks”.

5. Medication Ordering, Collection, and Storage

Ordering and Prescription Management: The service will support service users in obtaining their medications. Depending on the care plan, staff may order repeat prescriptions from the GP on the service user’s behalf, with consent. We use the local GP surgery’s preferred ordering method (online requests, phone, or paper slips) and track when repeats are due so that the person does not run out of medication. When a new prescription is issued (for example, after a hospital visit or GP appointment), the care staff or office will coordinate with the pharmacy to get the medications promptly. Staff can also collect prescriptions or dispensed medications from the pharmacy if needed, or arrange delivery. A record is kept (in the care notes or eMAR system) of what medications are received and when.

Storage in the Service User’s Home: Medications will typically be kept in the individual’s own home environment. Even though this is a home setting (not a care home building), we still advise and ensure that medicines are stored safely:

• General Medicines: The person (with staff help if needed) should designate a safe, dry place out of reach of children or pets (if relevant) to store medicines. Ideally, a drawer or cabinet that is not damp (avoid bathrooms unless medicines specifically need refrigeration). We educate service users about keeping medicines in their original packaging with labels intact.
• Refrigerated items: If certain medications (like insulin or some liquid antibiotics) require refrigeration, staff must check that the fridge is in working order and within safe temperature range (2-8°C). We might provide a fridge thermometer if needed or ask the person/family to monitor fridge temperature. Medicines should be in a clearly marked container in the fridge to avoid mix-ups with food.
• Controlled Drugs (CDs): In a domiciliary care context, there is no legal requirement for a separate controlled drugs cabinet in the person’s home (unlike in a care home). The medication belongs to the individual, and it’s their home. However, for safety, if a service user is prescribed controlled drugs (e.g., strong painkillers like morphine, or sedatives), staff will advise the person to keep them in a secure place. If there are concerns (for example, other people in the house who might abuse them), the service may request a lockable storage box to be used in the home, with the key held by the service user or a trusted person. Staff should be aware of counting the quantity of controlled drug medication when they arrive and leave, if feasible, to quickly spot any discrepancies. Every administration of a controlled drug must be meticulously recorded on the MAR, including remaining stock if required by our procedures (some services keep a separate CD stock sheet even in home care to track usage). If staff ever have to transport controlled drugs (e.g., collecting from pharmacy), they should carry it securely and go straight to the service user’s home. Loss or theft of controlled drugs is treated very seriously and must be reported immediately (see Section 10 on incidents).
• Multi-Compartment Compliance Aids (MCA): These are dosette boxes or blister packs that pharmacies prepare, with medications sorted by day/time. If a service user uses an MCA, staff must still verify the printed description and time on the pack before giving the contents. MCAs should be stored like any other medicine – in a safe, dry place. Note that some meds (like soluble tablets or those needing refrigeration) might not be in the MCA; staff must refer to the MAR chart for all items, not just rely on the blister pack. The Royal Pharmaceutical Society defines MCAs as a repackaging system for solid doses, and they caution that not all medicines are suitable for such packs. Our policy is to only use MCAs if a pharmacist and GP have agreed it’s safe for that person’s medication regimen. If an MCA is in use, staff should never mix pills into a different container – they administer directly from the MCA.
• Topical Products and Other Routes: Creams, ointments, eye drops, inhalers, etc., should also be stored appropriately. Creams and drops might be in bedside drawers if used there – staff should ensure lids are tightly closed and note expiry dates (some eye drops expire 28 days after opening, for example). Inhalers might be near the person’s seating area. We’ll document where items are usually kept so any staff member can find them when needed. Staff should encourage service users not to scatter medications around the home, to prevent missed doses or accidental taking. A tidy, designated medicine area is ideal.
• Controlled Drug Keys: If a lockable box is used and staff hold a key on the service user’s behalf (this is rare and only by agreement), a key management procedure will be in place. Typically, the person should have access, but if not (due to safety), then each visit the staff retrieve the key from a secure place known to authorised persons. All such arrangements must be documented in the care plan with the person’s consent.

Labeling and Information: Staff should only use medications that are clearly labeled by the pharmacy with the person’s name, drug name, dose, and instructions. If any medication is found with no label or an unclear label (e.g., a homemade remedy or old bottle), staff must not administer it and should report it to the manager to decide how to dispose or clarify it. Each medication must have accompanying information – at least the patient information leaflet or pharmacist’s notes – which staff can refer to for guidance (though any concerns or questions about a medication’s use or side effects should be directed to a pharmacist or GP).

Stock Management: For each person, we try to maintain an appropriate supply of their medications. Staff should be vigilant about quantities – e.g., noticing if only a few days of pills remain – and prompt re-ordering in advance. Excess stockpiling is also avoided; generally, no more than 28 days’ supply is kept unless circumstances dictate (like 56 days for a two-month cycle). For controlled drugs, only the prescribed amount should be in the home; if there is excess due to dose changes, consult the pharmacist/GP about returning extras.

Homely Remedies (Over-the-counter medicines): In a person’s own home, they might wish to take non-prescription medicines (like paracetamol for a headache, or herbal supplements). Our staff cannot administer or suggest any non-prescribed medicine without it being agreed in the care plan. If the service user on their own decides to take an over-the-counter remedy, staff should note this in the daily notes if they’re aware (especially to inform healthcare professionals). Ideally, the service user or family should inform the GP of all substances being taken. We do have a Homely Remedy protocol: if a person frequently needs a simple remedy (e.g., occasional laxative or painkiller), we ask their GP for written permission or include it in the care plan that staff may assist with that specific over-the-counter medicine under defined conditions. This ensures safety and that it doesn’t conflict with their other meds. Any homely remedy given by staff is recorded on the MAR like a regular medicine, with reason and outcome noted. If no GP approval, staff must refrain and advise the person to seek medical advice for any new medication they want to try.

6. Medication Administration Process

This section describes the step-by-step procedures for safe medication administration or support, covering preparation, administration techniques for different forms of medicine, and post-administration recording. All staff must follow these steps to ensure consistency and safety.

6.1 Preparation and Verification

Before giving any medicine, the care worker should prepare by:

1. Reviewing the MAR/eMAR for the scheduled time to see which medications are due. The eMAR prompts staff with the list of medications due at that visit/time slot.
2. Gathering the medicines needed – for example, taking the tablets from the storage spot or assembling the inhalers, etc. Only bring out what is needed for that individual at that time to avoid mix-ups.
3. Hand Hygiene: Wash or sanitise hands before handling any medications. If needed, wear disposable gloves (especially for applying creams, eye drops, or handling tablets that should not be touched directly).
4. Verify Identity: Confirm you have the right service user (especially important if multiple people in one household or in a sheltered housing setting). Use at least two identifiers: ask the person’s name and birthdate, and/or check their care plan photo if available. Even if it seems obvious, best practice is to always confirm identity verbally.
5. Check each medication’s details:
   • Right Medication Name (does it match the MAR entry and the label?),
   • Right Dose (e.g., 2 tablets or 5ml – compare MAR and label),
   • Right Time (is it due now? e.g., morning vs evening dose),
   • Right Route (oral, topical, PEG, etc., ensure form matches route – e.g., don’t crush a tablet unless authorised by pharmacist for PEG use),
   • Right Person (as above, identity confirmed),
   • Right Documentation ready (MAR open to sign),
   • Expiry Date if applicable (check that the medication hasn’t expired, especially important for things like insulin vials, eye drops, etc.),
   • Allergies: be aware of any allergies (noted in care plan) to ensure nothing given could trigger an allergy.
6. Consent and Communication: Explain to the person what medications are due in a friendly, clear manner: e.g., “I have your morning medications here – your blood pressure pill and cholesterol tablet. Is it okay to help you with these now?” Gaining consent each time respects the person’s rights. If the person asks questions (“What is this one for? Do I still need it?”), staff should answer to the best of their knowledge or check the Medication Information File if available. If the person expresses reluctance or refuses, do not force or deceive them. Instead, try gentle encouragement or explanation of why it’s important, but ultimately respect their choice and follow the refusal procedure (document and notify, see Section 10.2).
7. Positioning and Readiness: Ensure the person is in an appropriate position to take the medication safely. For oral medications, the person should be upright (sitting or standing) and fully alert. Prepare a full glass of water (or other preferred fluid, noting any fluid restrictions or recommendations). For those with swallowing difficulties, follow any specific instructions (like use of a thickener or giving one pill at a time with plenty of fluid). For topical meds, ensure privacy (e.g., if applying cream to a private area, do so respectfully and with consent).
8. Focus and Avoid Distractions: During the medication administration process, the care worker should minimise distractions. Do not rush or multitask in a way that could cause loss of focus. It’s advised not to engage in unrelated conversation, phone calls, or tasks until all medications are administered and recorded. If an unavoidable interruption occurs, start the verification process again to ensure no step is missed.

6.2 Direct Administration Procedures

Different forms of medication require different handling techniques. Staff should follow the specific instructions for each type:

• Oral Tablets/Capsules: After verifying the correct medication and dose, transfer the tablet(s) from the container to the person. Avoid directly touching pills; tip them from bottle or blister pack into the cap or a medication cup, then into the person’s hand or onto a spoon. Offer the person the pills and the glass of water. Encourage them to drink a sufficient amount of water to swallow the medication. Stay with the person until you are confident the medication has been swallowed (especially important for people who might cheek the tablet or have swallowing issues). If a tablet is dropped on the floor or otherwise contaminated, do not use it; dispose of it safely (in a sharps bin or as per disposal guidelines) and get a new dose for the person (and later adjust the stock count). If the medication is a sublingual or buccal tablet (dissolves under tongue or in cheek), instruct the person accordingly and do not give water immediately after unless directed.
• Oral Liquids (Syrups, Solutions): Shake the bottle if required (check label for “shake well”). Use a medication spoon, graduated cup, or oral syringe to measure the exact dose in millilitres as prescribed. Measure at eye level if using a cup to ensure accuracy. Administer the liquid slowly, allowing the person to swallow. For thick liquids or those with strong taste, offering a water chaser or a bite of food (if allowed) can help after administration. Rinse the measuring device after use (if it’s to be reused by the same person) and store it hygienically.
• Inhalers (Bronchodilators, etc.): There are different types:
  • Metered Dose Inhalers (MDIs) – often used with a spacer device. If the person can self-administer but just needs prompting, hand them the inhaler and observe technique (we can prompt “don’t forget to breathe out first, then slow deep breath in as you press it”). If the person needs assistance, attach the spacer (if they have one), shake the inhaler, place it, have them seal lips around the spacer mouthpiece, press the canister to release a puff, and have them inhale slowly and deeply, then hold breath ~10 seconds. Wait about 30-60 seconds before a second puff if prescribed. Record number of puffs given.
  • Dry Powder Inhalers (DPIs) – e.g., Diskus or Turbohaler. These require the person to inhale quickly and forcefully. Staff can help by loading a dose (e.g., twisting the inhaler to load) and then instructing the person to exhale, position, inhale sharply. If the person cannot generate enough inhalation force, inform the prescriber (they might need a different device).
  • Always note in the MAR if an inhaler was given as a PRN (when needed) and the reason (e.g., “2 puffs Ventolin given for wheezing”). Check the remaining doses (some inhalers have counters) to know when replacement is needed.
• Topical Medications (Creams, Ointments, Patches):
  • For creams/ointments: Verify site of application and any instructions (e.g., “apply sparingly to rash on forearm daily”). Wear gloves, apply the medication as directed (a thin film vs. rubbing in, etc.). Do not double-dip fingers into a pot; use a clean spatula or different part of glove if more cream is needed to avoid contaminating the container. After application, ensure the person is comfortable and the area is not left exposed if it shouldn’t be (cover with dressing or clothing as appropriate). Remove gloves and wash hands.
  • For transdermal patches (e.g., pain relief or nicotine patches): Check when the last patch was applied and where. Rotate sites per instructions (often patches come with a diagram or described rotation schedule). Remove the old patch carefully and fold it in half with the adhesive sides together (to avoid drug leakage; dispose of it in a manner safe from children/pets). Apply the new patch to clean, dry, hairless skin in an appropriate area, pressing it firmly for about 10 seconds. Write the date/time (and initials) on the patch with a soft marker if required by protocol (some services do this to track). Document patch application on MAR including location on body if relevant (some eMAR allow attaching a body map).
  • For eye drops/eye ointments: Confirm which eye (left, right, or both). Ensure the dropper or tube is clean. Tilt the person’s head back or have them lie down. Gently pull down the lower eyelid to create a pocket and drop the correct number of drops into that pocket (or apply a thin line of ointment inside the lower lid). Instruct the person to close their eye gently for a minute; dab away excess with a clean tissue. Do not touch the eye with the dropper tip. If multiple different eye drops are given, wait a few minutes between them (usually 5 minutes, unless specified).
  • For ear drops: Have the person tilt the head so the affected ear is upward. Pull the pinna (ear lobe) gently up and back (for adults) to straighten the canal. Administer the prescribed number of drops. Ask the person to remain in that position for a minute or two to let drops penetrate. Use a tissue to catch excess, and advise the person not to get up too quickly if it affects balance.
  • For nasal sprays: Ask the person to blow their nose first if possible. Tilt head slightly forward, insert spray tip into nostril (per instructions), and have them inhale gently as you squeeze the spray. Repeat for other nostril if prescribed. Avoid touching the septum with the tip.
• Injections: As a standard, our care staff do not administer injections unless specially trained and authorised (see Section 8). If a staff member is assigned to assist with insulin, for example, they will follow the specific training protocol: verify blood sugar if needed, use an insulin pen at the proper dose, clean the injection site (if required by policy), pinch skin, inject at correct angle, dispose of the needle in a sharps bin. They must also observe the person for any signs of hypoglycemia or other adverse reactions afterward. For most cases, injections are done by healthcare professionals, so our normal procedure is to prompt the person if they self-inject or simply be aware of the schedule and ensure a nurse attends.
• PEG Tube Medications: As noted, only trained staff under delegation handle PEG medication delivery. If performing, they will check the PEG site, position the person (usually semi-upright), flush the tube with water (per ml as instructed), administer one medication at a time (each liquid or dissolved med via syringe into the tube), flushing with water between each to clear the tube, and again flush at end. They ensure the tube is clamped or closed properly after. All details of PEG administration (water amount, any issues) are recorded as per the care plan. If any resistance is met or the person shows distress, stop and get medical help.
• “When Required” (PRN) Medications: Some medications are prescribed not on a fixed schedule but to be given only when symptoms indicate (e.g., painkillers, laxatives, sedatives). The care plan will have a PRN protocol for each, describing:
  • the condition or symptom it should be used for (e.g., Paracetamol for body pain or temperature above 37.5°C),
  • the minimum interval between doses (e.g., “every 6 hours as needed, max 4 doses in 24h”),
  • the maximum total dose in a day,
  • how the person indicates need (the person might request it, or staff may observe signs like facial grimacing for pain in a non-verbal person). Staff must assess and confirm the need. If unsure, do not give until clarified. If given, they must document it on MAR with the exact time, dose, and reason (“PRN given for…”). Later, they should document the outcome/effectiveness if observable (“pain eased after 30 min”). If PRN is offered and the person declines, or if not effective and another dose might be needed earlier than allowed, inform a supervisor or GP for guidance.
• Covert Administration: (Detailed in Section 6.2 note and earlier) – Only proceed if an authorised covert medication plan is in place. The process for giving covertly (e.g., mixing crushed pill in applesauce) should be clearly outlined in writing by the prescriber/pharmacist. Staff should prepare the medication out of the person’s view (to maintain the “covert” aspect), ensure it’s well disguised in the food/drink, and then offer that food/drink in a normal manner. Extra care is needed to ensure the entire dose is consumed (or an estimate of how much, if not finished, to inform doctor). Record on MAR as given covertly (some MARs have a code for covert administration to indicate the person was not aware). Covert administration must be regularly reviewed – it’s a last resort method.

Throughout the administration process, staff should remain attentive and caring. Explain each step as appropriate (except in covert situations), and ensure the person is comfortable. If the person has questions or objections at any point, pause and address them if possible rather than pushing through a task.

6.3 After Administration – Recording and Monitoring

After assisting with or administering medication, the staff member must immediately record the details on the Medication Administration Record (MAR). In our service, we utilise an electronic MAR (eMAR) system, which each staff member updates in real time via a secure mobile application (see Section 7). The record includes:

• Marking each medication given with a confirmation (such as tapping a checkbox or selecting “Given” or the appropriate code).
• If a dose was prompted but ultimately taken by the individual, the eMAR allows a note indicating “prompted – client took medication self” or similar.
• If a dose was assisted, staff can log it as given (since the person did take it) but add a note “assisted with opening/pouring” if needed for clarity.
• If a dose was omitted or refused, the staff selects the reason code (e.g., “R” for refused, “O” for other omission, “S” for self-administered without staff, etc., as per our system’s coding) and enters a comment (e.g., “Refused – client said not feeling well, will try later. Informed senior.”).
• For PRN medications, document both the giving and the reason (“given for headache 7/10”) and later (next visit or handover) note the effect (“client resting, says headache improved”).
• Sign off with electronic signature: our eMAR automatically tags the entry with the staff member’s identity and timestamp.

The importance of timely recording cannot be overstated: it provides an accurate, legal record and informs any other staff accessing the MAR of what has just occurred (preventing double dosing or confusion). Forgetting to sign or record is considered a medication error in itself, so staff are trained to do it before leaving the client’s home, ideally immediately after administering each medicine (or all at end if that’s more practical, but never later than the visit itself).

Monitoring the Individual: After giving medication, especially new medications or high-risk ones (like opioids, insulin, anti-seizure meds), staff should monitor the service user for a short period. For example, ensure they don’t exhibit signs of an adverse reaction such as dizziness, allergic reactions (rash, swelling, difficulty breathing), excessive drowsiness, or other changes. If observed, take appropriate action (e.g., sit them down, check blood pressure if trained and equipment available, call for medical advice). If everything is normal, continue with the visit’s other tasks if any, or leave knowing the person is stable.

Communication and Handover: If another staff member or healthcare professional will see the person later in the day, communicate any important info about the medication given. For instance, if at lunchtime the person refused a dose, inform the evening staff to see if they will take it later (if still within safe timeframe). Use our internal messaging or note system to relay these messages.

If family or informal carers are involved in some medication times (e.g., we do mornings, family does evening), maintain a communication notebook in the home or electronic log that both parties can see. Record what we did and read notes from others. This ensures continuity and that, for example, a family member knows if a lunchtime dose was missed so they can be alert in the evening.

Documentation of Changes or Errors: If during the administration something unusual happened (like a dose was dropped and replaced, or a tablet was found already missing from blister), document that in the daily notes or incident form as appropriate (and inform the manager). The MAR might have limited space, so a brief entry plus a more detailed incident report may be necessary. Always ensure any change (like early discontinuation by GP order) is clearly marked and communicated.

By following these detailed administration steps, we aim to minimise errors and ensure each person gets maximum benefit from their medications. Staff competence in this process is verified regularly (Section 9 covers training and competency).

7. Electronic Medication Administration Records (eMAR) System

Our service uses an Electronic MAR system to manage medication administration records. This modern approach supports accuracy, real-time monitoring, and robust audit trails, meeting both service needs and regulatory expectations. Below is how we use eMAR and ensure its effectiveness:

• System Overview: Each care staff member has secure login credentials to the eMAR application on their work-issued smartphone or a designated device. The system contains each service user’s medication profile: a list of current medications with dosages, times due, and instructions (these are input by our office based on the GP’s prescription and pharmacy information). The eMAR prompts staff with a checklist of medications due during their scheduled visit.
• Real-Time Recording: As described in Section 6.3, staff record the administration or support event in real time. The eMAR captures the exact time an entry is made and who made it. This means that managers can see immediately if a dose was missed or is late. For example, if a 9am medication is not recorded by 9:30am, the system can flag an alert for follow-up. This immediacy is a key safety feature – it allows quick action (a phone call to the carer or service user to check) if something was overlooked.
• Accuracy and Decision Support: The eMAR helps reduce mistakes by:
  • Listing full medication details (name, strength, form) and often a photo of the pill or package to aid identification.
  • Displaying special instructions clearly (e.g., “Take with food”, “Do not crush”, “Check pulse >60 before giving”).
  • Preventing forward progression until each due medication is accounted for (staff must mark each item as given, refused, etc., before they can close out the task).
  • Some systems allow scanning of medication barcodes which electronically verify the “7 rights” of medication against the MAR. If our eMAR supports this, staff are trained to scan the medicine pack, and the system will confirm if it’s the correct drug and dose for the right person and time. This feature helps catch any selection errors (for instance, if a staff accidentally picked up the wrong client’s blister pack, the barcode would not match and would alert them).
  • Built-in dose calculators or alerts for certain meds (e.g., if PRN paracetamol was given recently, an alert might warn “last given 4 hours ago, max 4 per day”).
• Audit Trail: Every action in the eMAR is logged. Managers can generate audit reports that show, for example, all administrations by a particular worker, all missed doses for a period, or any edits made to records. The system retains historical data securely, so if an inspector or auditor wants to review MAR for a specific date, we can retrieve it easily. Because entries are time-stamped and user-stamped, any late entry or alteration is clearly indicated (preventing any attempt to falsify records). This transparency encourages staff accountability and supports investigation if something goes wrong.
• Privacy and Security: The eMAR system is password-protected and encrypted. Staff must not share logins. Mobile devices are configured with security measures (PIN/fingerprint and remote wipe capability if lost). Data is stored in compliance with GDPR and NHS data security standards. Only authorised personnel (care staff for their assigned service users, and managers for oversight) can access the records. If a staff member leaves employment, their access is promptly revoked. Regular audits of user access are done to ensure no unauthorised viewing of records.
• Contingency (Downtime Procedures): In the event of technical issues (device failure, network outage, system maintenance), we have a backup paper MAR process. A current paper MAR chart or printed medication list is maintained for each service user either in their home or at our office, so it can be deployed quickly if eMAR is inaccessible. Staff are trained to revert to paper documentation if needed, then later transcribe or submit that information to management for input into the eMAR once restored (with appropriate annotation of it being a backdated entry). We test this contingency periodically in drills (e.g., simulate a system outage) to ensure staff can manage safely without the electronic aid for a period. Communication via phone will be used if needed to verify doses during an outage.
• Integration with Care Plans: Our electronic system integrates medication records with care planning. When a service user’s support plan is updated (for example, noting a new allergy or a change in self-management ability), the medication profile is also reviewed. Conversely, when a new medication is added in eMAR, staff are prompted to update the personal plan to reflect this (like ensuring the risk assessment includes that medication). This ensures consistency and that all documentation is aligned.
• Audit by Inspectors: The Care Inspectorate is familiar with eMAR usage in care at home. During inspections, inspectors may ask to see how our eMAR works, review specific records on-screen or in print, and verify we have effective audit processes. We will readily demonstrate the system and provide any requested reports. We ensure that our eMAR meets the record-keeping guidelines (e.g., clear, contemporaneous entries, signed and dated) that the Care Inspectorate expects. In effect, our eMAR system is a tool to enhance compliance with the requirement to maintain accurate medication administration records and to evidence good practice.
• Training on eMAR: All staff receive training on how to use the electronic MAR, including practice scenarios. Competency in using the device and app is assessed (some staff may be less tech-confident, so we provide extra support as needed). We include instructions on what to do if something doesn’t seem to log correctly, and whom to contact for tech support. Also, staff are reminded that the principles of safe administration still apply – eMAR is an aid, not a substitute for critical thinking (for example, they must still check the actual medicine label against eMAR; if eMAR says give 2 tablets but the label says 1, they should stop and resolve the discrepancy, not blindly follow eMAR).
• Benefits: Using eMAR has improved our accuracy, accountability, and oversight. It reduces illegible handwriting issues, provides instant oversight for supervisors, and helps demonstrate compliance with standards (since everything is time-stamped). It also simplifies auditing and responding to any concerns (we can quickly search records). While technology has a learning curve, our staff have adapted well and appreciate features like reminder alarms and drop-down selection that streamline their work.

In summary, the electronic MAR system is an integral part of our medication management, ensuring accuracy, accountability, and an auditable trail of all medication activities. It aligns with modern best practices and meets regulatory expectations for record-keeping and monitoring, while also facilitating easier audits and oversight by both our management and external inspectors.

8. Special Considerations: Controlled Drugs and PEG Medications

Certain medications and routes of administration require extra caution and specific protocols due to their potent nature or invasive delivery. This section details how we handle Controlled Drugs (CDs) and medications given via a Percutaneous Endoscopic Gastrostomy (PEG) tube, as well as other specialized tasks, in compliance with legal requirements and best practice guidance.

8.1 Controlled Drugs (CDs)

Controlled Drugs are medicines that are more tightly regulated by law (Misuse of Drugs Act and associated regulations) due to risk of misuse, addiction, or harm. Common examples in home care might include opioid painkillers (morphine, oxycodone, fentanyl patches), certain anti-anxiety or sedative drugs (diazepam, temazepam), or stimulants for ADHD. Our policy for CDs includes:

• Administration by Care Staff: It is permissible for care at home staff to administer controlled drugs if they are part of the service user’s prescribed regimen. We treat controlled drugs like any other prescribed medicine in terms of ensuring the right dose, time, etc., but with added safeguards. If the service user’s needs include controlled drugs and a provider were to refuse to handle them, they likely would not be meeting the person’s needs. Therefore, we do handle CDs, with robust procedures.
• Storage: As noted in Section 5, there is no legal mandate for home CD cabinets, but security is emphasized. We advise service users to keep CDs out of sight and reach of others. If there’s a concern about potential misuse by someone else in the household, we involve the service user (and family if appropriate) in finding a safe solution, such as a locked drawer or a small safe. We also limit quantities in the home by coordinating more frequent pharmacy dispensing if needed (e.g., weekly instead of monthly for high-risk meds).
• Recording: Every dose of a controlled drug administered must be recorded on the MAR as usual, and ideally tracked via a count. In a domiciliary setting, we may not maintain a bound CD register on site as a care home would; instead, our eMAR system flags CD administrations and we can run separate CD audit reports. However, for added safety and accountability, we keep a Controlled Drug log sheet in the service user’s folder at home or in our office records for that client. On this log, staff record each administration of a controlled drug, the amount given, and the remaining stock (by count or volume), signing (and having a second signature if another staff is present). Staff should check the remaining stock each time against what is expected. If any discrepancy is found (e.g., missing tablets or extra tablets), this is reported immediately to the manager for investigation – it could indicate a recording error, an incorrect dose given at some point, or a security issue.
• Witnessing: Whenever two staff are present (during a double-up visit or training overlap), we require that both staff witness the preparation and administration of controlled drugs and sign the MAR/record. This double-check adds safety (one reads the prescription, the other prepares, both agree before giving). In single-staff visits, we rely on the staff to be extra vigilant. If the risk level is high (e.g., very potent drug or history of errors), we might arrange two staff for those visits specifically to ensure safer practice.
• Disposal of Controlled Drugs: If a controlled drug is discontinued or expired, staff must not dispose of it in normal trash. Instead, such medication should be returned to a pharmacy for proper destruction. We will arrange with the service user and pharmacy to do this safely. Two staff (if possible) should oversee the removal of the controlled drug from the home (count the quantity being returned, document it, and transport it securely to the pharmacy). The pharmacy should provide a receipt or at least acknowledge which drugs were handed in. We log this in the CD log sheet (e.g., “5 tablets of morphine 10mg returned to Jones Pharmacy on 12/12/2024 – signed X (staff), Y (pharmacist)”). Used transdermal patches still contain drug, so after removal, staff fold them and dispose of them in a sharps or pharmaceutical waste bin if available, or return them to pharmacy in a bag for destruction (to prevent anyone finding them in trash). If a controlled drug dose is prepared but not used (e.g., person refused after it was drawn up, or dropped pill), it must be destroyed in a safe manner (liquid can be squirted into a tissue and bagged, pill can be crushed in tissue) and recorded as wasted.
• Incident Reporting: Any incident involving a controlled drug (error, refusal of an essential dose, missing pills, etc.) triggers immediate management attention. We follow the error protocol in Section 10. Additionally, the Care Inspectorate requires notification of incidents involving controlled drugs. We will submit a notification through their eForms for any significant CD incident (for example, a dosing error with morphine, or suspected diversion of a drug). This is in line with “Notifications about controlled drugs: guidance for providers” which we abide by. We also inform the prescriber of the incident and seek medical guidance on any health implications.
• Handling by Staff: When staff carry controlled drug prescriptions or pick up controlled drugs from pharmacy on behalf of a client, they should carry identification as some pharmacies require it. Staff must transport it directly and not leave it unattended (e.g., don’t leave it in a car in view). Once delivered to the service user’s home, it should be logged in the records as received (with quantity). Staff should never take home any controlled drug for safekeeping; it should always be in the possession of the service user or secured at their home unless in transit.
• Equality and Respect: We handle controlled drugs without stigma towards the service user. These medications are for legitimate medical use and the person should not feel ashamed to be on them. We ensure privacy when administering (so that neighbours or visitors are not made aware unless the person chooses to tell them). We also recognise these meds can be critical for pain or symptom control, so timely administration is a priority (e.g., not delaying a morphine dose because “the schedule says later” if the person is in pain and it’s within allowed parameters).

In summary, controlled drugs are handled with the highest diligence, treating them as a normal part of care but recognizing their potential for harm if mismanaged. This ensures we meet both the legal standards and the Care Inspectorate’s expectations on controlled drug governance.

8.2 PEG-Administered Medications and Other Specialised Techniques

Some service users may require medications via a PEG tube or other non-oral routes that are beyond standard tablet/capsule administration (e.g., rectal administration, injections, infusion pumps). Generally, such tasks are considered healthcare procedures and not normally undertaken by care staff unless explicitly delegated by a healthcare professional, with proper training. Our policy on these specialised medication administrations is:

• PEG (Percutaneous Endoscopic Gastrostomy) Tube: Medication administration through a PEG is typically done by nurses, but in a domiciliary setting, if it’s in the person’s best interest for our staff to do it (for timely visits, etc.), we require:
  • Healthcare Professional’s Delegation: A registered nurse (e.g., district nurse) or other appropriate professional must assess the situation and delegate the task in writing. They should provide a clear care plan for PEG medication administration (including flushing protocol, what to do if blocked, emergency contacts).
  • Consent: The person (if they have capacity) or their legal representative (Power of Attorney or Guardian) must consent to our staff performing this health-related task. Without consent, we cannot take on the task.
  • Training and Competency: The staff members who will perform PEG tasks must be trained by a qualified professional (usually the delegating nurse). Training includes how to check tube placement (commonly by checking external markings, or pH of aspirate if trained to do so), safe flushing, dissolving medications, signs of complications (like infection at site or tube displacement). Each trained staff should demonstrate the procedure back to the trainer to be signed off. We keep a record of who is authorised for PEG tasks.
  • Care Plan Details: The plan will specify flush volumes (before and after meds), acceptable methods of giving meds (liquid form preferred; if tablets must be used, instructions on crushing/diluting as per pharmacist guidance), positioning of the person (usually at least 30 degrees upright), and any pre/post checks (e.g., check for residuals if instructed, or check blood sugar if feeding involved). It will also outline what to do in case of certain issues (like “if PEG appears blocked, do not force; call district nurse”).
  • Monitoring: Initially, a nurse may supervise our staff for the first few times. Ongoing, we might have periodic re-evaluations (say every 3 months the nurse observes once) to ensure standards.
  • Limits: Staff will not change a PEG tube or insert one if it falls out – that is strictly medical staff’s job. If a PEG falls out or malfunctions, we call emergency services or nurse immediately.
  • Our staff understand that although a nurse delegated it, they are responsible for doing it correctly each time and the delegating nurse remains accountable for the decision to delegate. We maintain an open line such that if any staff member feels uncomfortable at any point, they can pause and request nurse intervention without blame.
• Rectal Administration (Suppositories or Enemas): This is generally outside the scope of home care staff. Exceptions might be emergency medication for epilepsy (rectal diazepam) if no alternative is available – however, nowadays buccal midazolam is preferred and easier for non-nurses. If rectal medication absolutely must be given by our staff, the same delegation and training principles apply:
  • Explicit agreement from management, prescriber, and usually only in urgent or very specific situations.
  • Training by a nurse/doctor on how to administer, privacy concerns, and what to monitor.
  • Two staff would attend if possible (for dignity and also assistance).
  • Gloves and proper lubrication used, etc.
  • Post-administration, monitor effect (did they expel it too soon, any adverse reaction).
  • Document thoroughly.
  • This would be very rare and typically short-term (like a hospice at-home scenario where family or nurses can’t attend in time for seizures).
• Injections (e.g., Insulin, Low-Molecular-Weight Heparin): As mentioned, routine insulin injections can be delegated to trained support staff for stable patients:
  • We require an insulin administration course (often provided by local NHS) for any staff doing this.
  • They must understand diabetes management – signs of hypo/hyperglycemia, use of glucometer if needed, when not to give insulin (e.g., if blood sugar is too low or the person hasn’t eaten, depending on insulin type).
  • The care plan must specify insulin type, dose (or sliding scale), injection sites rotation, and what to do if blood sugar reading is out of target or if a dose is missed.
  • Staff will also know how to store insulin (fridge before use, or room temp when in use, depending on policy, and check expiry).
  • Sharps disposal: A sharps box is kept in the home; when 3/4 full, the staff arranges exchange (often via district nurse or community pharmacy).
  • For other subcutaneous injections (like blood thinners after surgery), similar approach: likely involve district nurse unless specifically arranged.
  • At no time will our staff administer intravenous medications or set up drips – that is beyond our remit.
• Special Feeding Pumps or Infusions: Sometimes medication can be given via syringe drivers or CADD pumps (like for pain in palliative care). Our staff do not set these up but may be present to ensure they are running (monitor for alarms on a pump and call nurse if needed, but not to troubleshoot beyond basic checks like power/battery). We will work with hospice or community nursing for those cases.
• Clear Boundaries: We explicitly list tasks that care staff cannot do in our training to avoid confusion. These include:
  • No mixing of injections or preparation of IV meds,
  • No adjustments to oxygen flow (beyond turning on/off as directed),
  • No administering of nebulizer unless trained (though nebulizer usage could be taught and it’s similar to inhaler in principle),
  • No prescription changes (they can’t decide to increase dose or give something early without instruction),
  • No force-feeding medication (if person resists, we follow refusal protocol, not physical force).

In summary, for PEG and other non-standard routes, we only undertake such tasks when it is clearly in the individual’s interest, all legal and professional requirements are met, and staff are trained and competent. Safety and adherence to proper clinical procedures are paramount. If a needed task falls outside our agreed scope, we will coordinate with community nursing or other services to ensure the person still receives what they need.

9. Staff Training, Competency, and Professional Standards

Safe medication management hinges on staff being knowledgeable, skilled, and following professional standards. In line with SSSC requirements and Care Inspectorate expectations, we invest in comprehensive training and ongoing competency assessment for all employees involved in medication support.

9.1 Training Requirements

• Induction Training: Every new care worker must undergo medication training as part of their induction before they are permitted to assist with or administer medication on their own. Typically, this involves a structured medication training course covering all basics: the 7 rights of administration, understanding medication types (tablets, liquids, patches, etc.), infection control (like hand hygiene and gloves), using MAR charts correctly, recognizing side effects, and what to do in various scenarios (missed dose, refusal, error). We use a course that meets the learning outcomes of the Safe Administration of Medication standards (such as SSSC’s online modules or accredited training). This training includes an assessment component (e.g., a written test or observed simulation) that staff must pass to demonstrate understanding.
• Policy Orientation: As part of induction, staff are required to read this Medication Policy in full. A supervisor or trainer will discuss key points with them to ensure understanding. New staff sign a statement acknowledging they understand their responsibilities regarding medication management, or complete a workbook that includes questions on our policy (for example, “What do you do if a service user refuses their medication?”) to ensure they’ve absorbed the content.
• Shadowing and Initial Supervision: After the theoretical training, new staff members will shadow experienced staff on medication visits. They observe how medications are checked and given, how the MAR is filled out, and how the service user is engaged. When the new staff is ready to practice, they will administer medication under the direct supervision of a senior staff member or mentor. Only when the supervisor is confident in their ability will the new staff be signed off to work solo on medication tasks. This staged approach helps new staff gain confidence and correct technique.
• Specialised Training: If a staff member is expected to handle specialised medication tasks (as per Section 8), they receive additional training. For example:
  • To assist with insulin injections, they complete a diabetes care training module.
  • To administer via PEG, they get training from a nurse (and often a competency check by that nurse or another qualified assessor).
  • For administering eye drops or use of inhalers, our basic training covers it, but if someone specifically has many clients with these needs, we might do a focused refresher on proper techniques.
  • Controlled drugs handling is emphasised in training due to its importance; scenarios involving counting and signing are practiced.
• Ongoing Training (Refreshers): We provide regular refresher training at least annually. This can be in the form of e-learning updates or in-person workshops. These refreshers cover any new guidance (for instance, if the Care Inspectorate releases a new medication guidance, or changes in SSSC Code), review common issues (like recent errors and how to avoid them), and reinforce good practice (like checking ID, reading labels fully). We also use refreshers to cover any new technology updates for eMAR or changes in our internal processes.
• Professional Development: We encourage staff to pursue relevant qualifications. Many of our support staff enroll in SVQ (Scottish Vocational Qualification) in Health and Social Care at level 2 or 3, which includes units on supporting medication. We may organise additional workshops with external trainers or pharmacists – e.g., a local pharmacist might give a talk on common medications in older people and their side effects, which helps staff contextualise what they do beyond just tasks.
• Management and Senior Staff Training: Those in oversight roles (like the Manager, Supervisors, Medication Champion) receive advanced training on medication management systems, auditing, and coaching staff. They stay current with Care Inspectorate updates and disseminate information to the team. The Manager ensures their own knowledge is up to date by attending webinars or forums on medication in social care, as available.

9.2 Competency Assessment

Training alone isn’t enough; we continuously assess that staff remain competent in practice:

• Direct Observations: At least annually, each care worker will have a medication administration competency assessment. A senior staff or the manager will schedule a time to observe the care worker during a routine medication round (with consent from the service user). Using a standardised checklist, they will evaluate the worker’s performance: Did they wash hands? Did they check the MAR and medication labels correctly? Did they identify the right person and explain the meds? Did they administer correctly and safely (proper technique)? Did they document immediately and correctly? etc. After the observation, the assessor provides feedback – praising good practice and pointing out any improvements needed. If any critical errors are observed during the assessment (which is rare since it’s usually seasoned staff being checked), the assessor would intervene if necessary and then arrange retraining. Generally, these observations help reinforce good habits and correct any drift in practice.
• Periodic Knowledge Checks: Supervisors may conduct unannounced spot checks or quizzes. For example, a supervisor arriving at a visit might ask the staff, “Tell me how you confirm you have the right person and right medicine?” or after the visit, “What would you do if [client] was not in when you arrived with their medication?” These keep staff on their toes and ensure they can articulate the policies. We also discuss medication scenarios in team meetings or supervisions, encouraging staff to share experiences and lessons (this reflective practice is a form of competency upkeep).
• Probationary Reviews: For new staff, during their 3-6 month probation, medication management is always a key point of review. We ensure they have had enough opportunities to demonstrate skill. If they are still unsure, we extend their mentoring period.
• Addressing Gaps: If a staff member is involved in a medication error or shows lack of knowledge in some area, we will require a targeted reassessment. For instance, after a mistake, the staff might be observed an extra time or asked to redo part of the training. Repeated issues might lead to more formal performance management.
• Staff Self-Reporting: We encourage a culture where staff can say “I’m not comfortable with this task” without judgement. If, for example, a staff member feels too nervous to give a controlled drug injection even after training, we might adjust assignments and provide more support until they gain confidence. It’s important staff are honest about their competence limits, as per professional standards.

9.3 Professional Standards (SSSC Codes and Care Standards)

All our staff are either registered or in process of registering with the SSSC, which binds them to the SSSC Codes of Practice. Key aspects of these codes relevant to medication include:

• Code for Workers: Requires them to protect the interests of service users, which means administering medication in the service user’s best interest and strictly according to need. They must maintain trust and confidence – mishandling medication can severely erode trust. They are to promote independence (so not take over medication tasks the person can do) and respect the rights of service users (including the right to refuse medication). The code also explicitly says workers must maintain clear and accurate records and report matters that might affect the safety of service users or their care quality. This includes reporting medication errors or any difficulties with medication management. They must also uphold public trust and not bring the profession into disrepute – e.g., stealing medication or being under the influence of drugs at work would be gross violations.
• Code for Employers: (which applies to our service as the employer) mandates that we provide appropriate training, policies, and support to staff for them to perform their duties safely. It also says we must have systems to manage and monitor work – which is exactly what our audits and supervisions do – and address dangerous or incompetent practice if it occurs. This policy and our procedures are part of fulfilling those obligations.

We also align with the Health and Social Care Standards (HSCS) in daily work:

• Standard 3.14: People have confidence in staff because they are trained, competent and skilled, and follow their codes. Our training and competency framework ensures staff meet this.
• Standard 4.11: Care and support is based on relevant evidence, guidance and best practice. This policy is based on current Care Inspectorate guidance (e.g., prompting/assisting definitions) and professional guidelines, which we update as these evolve.
• Standard 4.19: Service users benefit from a culture of continuous improvement with robust quality assurance, which we enact through audits and learning from incidents.
• Standard 2.17 (for instance): “I am fully involved in managing my medication, if I want to be” (paraphrased) – we ensure individuals who want and can manage their meds are supported to do so, reflecting choice and control.
• Standard 1.24: “Any treatment or intervention I experience is safe and effective”– safe medication administration is a cornerstone of this, making sure people get the right meds without error.

By ensuring our staff training and practices meet these professional standards, we protect service users and also support our staff’s development. If any staff member’s practice falls below these standards, we treat it seriously – with retraining, supervision, or if needed, disciplinary action – because mishandling medication can have severe consequences and would breach both this policy and their professional code.

9.4 Record Keeping and Accountability

An important part of training and standards is emphasizing the significance of accurate record keeping. Staff are taught that if it’s not recorded, it’s considered not done in the eyes of regulators. Therefore, they must sign for everything they do, and never sign for something they didn’t do. Falsifying records is considered gross misconduct and a violation of SSSC codes (honesty and integrity). We also remind staff that records could be reviewed by others (managers, inspectors, other health professionals) and by the service user themselves or their family, so clarity and truthfulness are crucial.

We also implement the Duty of Candour requirements: if something goes wrong that causes harm, we have a duty to explain, apologise, and take action. We incorporate this into our training – meaning if a staff makes an error, they are expected to be open about it, not hide it, and to participate in putting things right.

In conclusion of this section, our staff training and competence assurance processes are robust, ensuring that those who handle medication are qualified and capable. This gives confidence to service users, their families, and regulators that medication support is delivered safely and professionally, consistent with SSSC codes and Care Inspectorate standards.

10. Medication Errors, Incidents, and Safeguarding

Despite best efforts, mistakes or issues with medication can occasionally occur. It is critical that these are handled promptly, transparently, and effectively to ensure the well-being of the service user and to prevent future incidents. This section describes our protocols for medication errors and omissions, and how we manage safeguarding concerns related to medication.

10.1 Medication Errors and Near Misses

A medication error is any deviation from the prescribed medication regimen or procedures. This includes giving the wrong medication or dose, giving it to the wrong person, giving at the wrong time (significantly early/late or entirely missed), using the wrong route, or administering a medication that was not prescribed (e.g., another person’s medication). Near misses (where an error was caught before the medication was taken) are also taken seriously, as they often indicate a system weakness or lapse that could recur.

Immediate Actions if an Error is Discovered:

• Ensure Safety of the Service User: This is the top priority. Depending on the nature of the error:
  • If the wrong medication or an incorrect dose has been given, or a critical dose has been missed, seek medical advice immediately. Contact the GP or NHS 24 (111) for guidance; if the person shows any signs of distress or the medication has high risk (e.g., insulin, heart medication, strong analgesic), call emergency services (999) without delay. Have information ready: what medication/error occurred, the time, and the amount involved.
  • Monitor the individual’s vital signs if possible (pulse, level of consciousness, etc.) while awaiting advice. Do not leave them alone. If family or another responsible person is present, inform them of the situation so they can assist in monitoring.
  • Follow any instructions given by healthcare professionals (e.g., administer a remedy like glucose for insulin overdose, or simply observe and report changes).
  • If the error was a missed dose and some time has passed, check with a pharmacist or GP whether it should be taken late or skipped. Do not double dose the next time unless explicitly instructed by a doctor (e.g., some contraceptive pills or steroids might have catch-up protocols, but most medications do not).
• Inform the Individual (and Family if appropriate): As part of our Duty of Candour and ethical practice, explain to the service user in an appropriate manner that an error has occurred. Apologise for the mistake and explain what is being done about it (e.g., “I’m sorry, I gave you the wrong tablets. I’ve contacted the GP and we are monitoring you closely.”). If the person has cognitive impairment, also inform a family member or representative as soon as possible. Reassure them that their well-being is our priority and that we will investigate and prevent recurrence.
• Immediate Reporting: The staff member must notify their line manager or on-call manager immediately once the service user’s immediate needs are addressed. Even if it’s midnight, an on-call manager should be alerted for serious errors. Prompt reporting allows management to assist in decision-making (maybe they will come in person, or call emergency services themselves) and also start the documentation process.

Where to report:

1) Verbally to the Registered Manager or Safeguarding Lead

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

3) Call the office and inform the Registered Manager or Safeguarding Lead: {{org_field_phone_no}}

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

5) Online via our website: {{org_field_website}}

• Document the Error: As soon as the situation is stable, the incident must be documented:
  • On the MAR/eMAR, clearly mark the dose as not given or given in error (depending on what happened) with an explanation note (e.g., “Error: wrong med taken, see incident report” or “Omission: dose missed due to error, GP informed”).
  • Fill out a Medication Incident Report form, detailing: date/time, people involved, exactly what happened, what medication(s) and dose(s) were involved, the effects observed, immediate actions taken (including who was contacted and what they advised). If multiple staff were present, each can contribute to the report or make their own statements.
  • If the error was a near miss (caught in time), still record it as an incident, because we treat near misses as learning opportunities.
• Manager’s Investigation: The manager or delegated investigator will conduct a thorough review of the incident. This involves:
  • Interviewing the staff involved (in a supportive, fact-finding manner) to understand how the error occurred. Was it due to fatigue, misreading a label, not following procedure, or system issues like similar packaging?
  • Reviewing all relevant documents (MAR chart entries, care plan, prescriptions, training records of staff).
  • Determining the root cause (or causes). For example, if a label was confusing, that’s a system issue; if staff was rushing due to workload, that’s an organizational issue; if staff simply didn’t check properly, that’s an individual performance issue.
  • Checking if any policy or protocol wasn’t followed and why.
  • Evaluating the harm or potential harm to the service user. If the user required medical attention, that’s significant harm; if not, but could have been worse, note that.
• Notifications to Regulators: If the error had the potential for harm or actually caused harm, we will notify the Care Inspectorate as required. Generally, an error that reaches the service user (especially a controlled drug error) is notifiable. We fill out a formal notification form (via eForms) describing the incident and outcome. If required under Adult Support and Protection (ASP) guidelines (for example, if the error was due to negligence or resulted in serious injury), we also inform the local authority’s safeguarding team. Additionally, if the error is very serious or involves misconduct, we might have to inform the SSSC (since it could reflect on a worker’s fitness to practice) – but that typically would be if the error was due to reckless or unethical behaviour.
• Follow-up with Service User: We keep the affected service user and their family informed throughout. After the immediate event, the manager or senior will speak with them (and/or family) to formally apologize (if not already done) and explain what will happen next. If Duty of Candour criteria are met (unintended harm occurred that is serious), we follow that procedure which includes a written apology and explanation and an offer to meet and discuss the incident and the actions taken.
• Remedial Actions for Staff: Based on findings:
  • If the error was a one-off slip (human error), we treat it as a learning opportunity. The staff member might receive additional training or be asked to demonstrate competence again. We emphasise caution and following procedure. A note is kept in their supervision record.
  • If the error revealed a knowledge gap (“I didn’t realise I shouldn’t crush that pill”), then targeted re-education is done.
  • If the error was due to not following procedure (e.g., skipping identity checks), we treat that seriously. The staff may face disciplinary action depending on severity, but often we start with retraining and a warning. Repeated failure to follow procedure would escalate to formal warnings.
  • If the error involved misconduct (like covering it up or not reporting it, or deliberate misuse), that is disciplinary immediately and potentially reportable to SSSC for fitness to practice concerns.
• Systemic Improvements: We analyse if changes are needed to prevent recurrence:
  • Update the medication care plan to add precautions (like highlight on MAR “Two people have same last name in household – double check first names” or “Medication X sound-alike with Y – store separately”).
  • Re-train all staff on any new lesson (without naming anyone, we might say “We recently had an incident where a dose was given twice. We remind everyone to always initial MAR before preparing next person’s meds to avoid confusion”).
  • If we found workload or scheduling was a factor (staff rushed between too many visits), adjust the rota or staffing levels accordingly.
  • If equipment or packaging was a factor (e.g., tiny print on labels), talk to the pharmacy about solutions or provide staff with magnifiers or better lighting.
  • Check if the policy needs tweaking to clarify anything that was misinterpreted.
• Recording Outcomes: Once the investigation is complete, the manager documents the outcome and actions taken. This might be in the incident form (which becomes part of our records) and also in a summary log for trends analysis. If the Care Inspectorate was notified, we also update them on the outcome (sometimes done in the notification follow-up or during next inspection).
• Emotional Support: We acknowledge that medication errors can be distressing for staff as well as service users. We offer support to the staff involved – a debrief to talk it through, counselling if needed, and encouragement as they regain confidence. A blame-free approach (unless wilful misconduct) is important so staff report issues rather than hide them.

10.2 Medication Omissions and Refusals

Not every missed dose is a straight error; sometimes doses are omitted intentionally or by circumstance:

• Refusal by Service User: Individuals have the right to refuse medication. If a service user declines a medication:
  • The staff should try to understand the reason. Are they feeling side effects? Do they not understand why they need it? Gently provide information or address misconceptions if possible (“The doctor prescribed this for your blood pressure; without it, you might feel unwell.”).
  • Do not force or coax excessively. If they firmly refuse, respect their decision.
  • Mark it on the MAR as refused (“R” code) and write a note in eMAR or communication book: “Refused 8am dose of XYZ, said it upsets stomach.”
  • Notify the senior/manager, especially if it’s an important medication. The manager might inform the GP if missing doses could be harmful (GP might advise what to do or talk to the patient about it).
  • Continue to offer at next scheduled time unless advised otherwise, and document if they eventually take it or repeatedly refuse.
  • If refusals persist and the person lacks capacity to understand consequences, this may trigger a capacity assessment and possible covert administration plan or involvement of their Power of Attorney/doctor to determine best course (safeguarding the person’s health while respecting their rights).
• Service User Not Present or Unable: Sometimes a dose is missed because the person is out (maybe an appointment or they didn’t inform us they’d be away) or they are asleep and it might be unsafe to wake them (depending on instructions).
  • If the person is not home, the staff will try to contact them (phone or through family). If unable to give later the same day, mark as omitted and inform manager. The manager might coordinate a make-up visit or advise skipping until next dose, depending on medication criticality.
  • If the person is asleep, staff will use judgement: for critical time-sensitive meds (like Parkinson’s meds, pain meds), waking might be necessary – this should be clarified in care plan if they’ve consented to be woken for those. For others, if they’re just napping and will be up later, perhaps come back or hand over to family to give when the person wakes (if that’s in the plan). Document what happened and any instructions left (“Client asleep, daughter will give dose at 11am as per agreement”).
• Unable to Administer (Other): Maybe the medication wasn’t available (pharmacy delay) or dropped and no spare. In such cases:
  • If no stock, treat similar to missed – inform manager, arrange urgent pharmacy delivery, maybe GP can authorise an emergency supply if needed. Document “dose not given – medication not in house, pharmacy error, will give ASAP”.
  • If the person vomits after taking a medication (so effectively the dose may not have absorbed), call GP to ask if dose should be repeated. Document that advice (e.g., “vomited 10 minutes post-med, GP said to consider dose as not given and try again in 6 hours”).
• Logging and Monitoring Omissions: All omissions (whether refusal or not home, etc.) are recorded and the manager reviews them. Patterns (like someone frequently refusing their nighttime diuretic) are addressed by care reviews. We also distinguish between a “missed due to our error” versus “missed due to client choice or unavoidable event” in our incident logs.

10.3 Safeguarding and Medication

Medication mismanagement can be a form of abuse or neglect. We stay vigilant for any medication-related safeguarding issues:

• Overmedication or Misuse: If we suspect a service user is being overmedicated to keep them sedated or compliant (sometimes called “chemical restraint”), this is a safeguarding concern. For instance, if family members are giving extra doses without prescription to manage behaviour, or if a staff were to do so, it’s abuse. We would immediately report and intervene. Our staff are prohibited from giving any medication outside what’s prescribed and documented.
• Theft or Diversion: If medications, especially controlled drugs, are disappearing, we consider the possibility of someone taking them (could be a staff member, family, visitor). This is a serious adult protection and possibly criminal issue. We would report to management and likely the police if theft by anyone is suspected. Staff suspected would be suspended pending investigation. We’d also inform the GP so they don’t prescribe larger quantities and possibly switch to daily pickup to prevent misuse.
• Neglect: If a service user’s medication needs are consistently not met, it could be due to neglect. For example, if another agency or family was responsible for some doses and they routinely fail to give them, we would raise this with the multi-agency care team and possibly ASP if the person’s health is suffering. Similarly, if one of our staff was found to be skipping medication administration (not just a one-time error but intentional laziness or repeated neglect), that becomes a disciplinary and safeguarding matter; we’d remove that staff from duty and investigate thoroughly.
• Self-Neglect: Some individuals may hoard medicines or not take them properly in a way that endangers them. While it’s their right to make choices, if it reaches a level of severe self-harm risk, we involve social services to possibly trigger an Adult Protection case for self-neglect. We work with them to find solutions, maybe simpler regimens or other support, but safeguarding includes protecting people from themselves in extreme cases.
• Medication Errors as Significant Harm: If a medication error results in hospitalization, serious injury or illness, that could be seen under safeguarding as well (neglect/poor care). We handle those with transparency and might involve external agencies if needed to ensure accountability and learning.

Where to report:

1) Verbally to the Registered Manager or Safeguarding Lead

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

3) Call the office and inform the Registered Manager or Safeguarding Lead: {{org_field_phone_no}}

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

5) Online via our website: {{org_field_website}}

Safeguarding Protocol:

• Recognise: Staff are trained to recognise signs of medication misuse or abuse (like a family member refusing to allow the person to take pain meds because they think they’ll get addicted – thus leaving the person in pain, which is abusive).
• Respond: If a staff suspects any medication-related abuse, they ensure the person is safe (e.g., if suspect overdose given by someone, call 999), and then report to the manager immediately.
• Record: Factual recording of what was observed or said.
• Refer: Manager will involve external agencies according to local Adult Support and Protection procedures – this could be a direct call to the council’s Adult Protection hotline or discussing in a multi-disciplinary meeting.
• We will cooperate fully with any investigation by social work, police, or healthcare.

All staff also know the whistleblowing procedure – if they feel something is wrong and not being addressed internally, they can contact the Care Inspectorate or other bodies directly.

10.4 Incident Review and Continuous Improvement

All medication-related incidents (errors, near misses, frequent refusals, etc.) are reviewed regularly as part of our service’s quality assurance:

• We maintain an Incident Log specifically for medication issues. Each entry is reviewed by management. We categorise them by type (error, refusal, pharmacy issue, etc.) and severity.
• In management meetings (e.g., a monthly clinical governance meeting), we discuss these incidents to see trends. For example, if multiple errors are happening at a certain time of day or with a certain drug, we drill down into why (is it a complex regimen? do staff need more training at that time?).
• We also share learning points with the whole team (anonymised). “Dear team, please note: When using cream medications, ensure to double-check the name. We had a case of the wrong cream used as the tubes looked alike. Keep creams in separate labelled bags to avoid confusion.”
• Positive reinforcement is given when, for instance, a staff member prevented an error (like noticed pharmacy gave the wrong tablets and didn’t administer them). We highlight that as good practice in team communications. This encourages a vigilant culture.
• All significant incidents and our responses are also available for the Care Inspectorate to review. Inspectors often ask about how we handle errors. We can show them our incident reports, actions taken, and how we updated practice. Being transparent and having a clear audit trail of incident management helps demonstrate we are a learning organization committed to safety.

By handling errors and safeguarding concerns with a transparent, proactive approach, we ensure the safety of service users and maintain trust. The Care Inspectorate inspectors will look for evidence that when things go wrong, we respond properly – our incident records, notifications, and action plans will demonstrate this.

11. Audit and Quality Assurance in Medication Management

To ensure high-quality medication support, our service implements rigorous audit and monitoring processes. Regular audits help us verify that staff adhere to this policy, that records are accurate, and that any issues are caught and addressed. This aligns with the expectation that the organization has robust and transparent quality assurance processes (HSCS 4.19) and that care and support are based on relevant evidence and best practice (HSCS 4.11).

Key Components of Our Medication Auditing and QA:

• Routine MAR Audits: The manager or delegated senior conducts a monthly audit of all Medication Administration Records. For eMAR, this involves running reports for each service user for the past month and checking:
  • That all scheduled doses have a corresponding entry (to ensure no doses were left unrecorded).
  • All codes for non-administration (e.g., R for refused, O for other omission) have explanatory notes and that follow-up actions were taken appropriately.
  • Any medication incidents noted on MARs have corresponding incident forms completed.
  • PRN (as-needed) medication usage is consistent with care plan guidelines (e.g., not too frequent, and reasons documented).
  • Stock counts for controlled drugs, where applicable, match the records.
  • Signatures/initials are present for each entry (or electronic equivalents). If using paper for backup, ensure no gaps.

The auditor uses a checklist and notes any discrepancies or areas of non-compliance. Even minor issues like a missing signature are flagged to remind staff that completeness is vital. A summary of audit findings is recorded.

• Spot Checks and Home Visits: In addition to scheduled audits, we perform random spot checks. A supervisor might arrive at a service user’s home during a medication visit to observe (with consent) and ensure procedures are followed. They may also check the medications in the home against the MAR to see if tablets remaining align with what should be left according to records (this can catch if doses were given but not signed for, or if a dose was given twice, etc.). For example, if a blister pack should have 5 tablets left on Friday according to MAR, but 7 are left, something was missed or recorded wrong. Such spot checks are unannounced to get a true picture of practice.
• Care Plan and Medication Profile Reviews: Every time a personal plan is formally reviewed (at least every 6 months, or when needs change), the medication section is reviewed in depth. We confirm that:
  • The list of medications in the care plan matches what’s actually prescribed (we update any changes).
  • The level of support (prompt/assist/administer) is still appropriate or needs change (maybe the person improved and can self-administer one of their meds now).
  • Risk assessments around medication (like risk of refusal or side effects) are up to date.
  • Any recent incidents or hospitalizations related to medication are discussed and plan adjusted accordingly.
  • We also ask the service user for feedback: “Are you happy with how we support you with your medication? Do you have any concerns or suggestions?” This user input is valuable and documented.
  • The outcome of these reviews might trigger actions, such as requesting a GP medication review if we notice polypharmacy issues or many PRNs being used.
• Medication Audits by Pharmacists: We sometimes invite local pharmacists or our supplying pharmacy to conduct a medication audit/review for our service users (with their consent). Pharmacists can identify issues like duplications, interactions, or more efficient ways (maybe converting multiple times to once-daily regimes). While this is more of a clinical review than an audit of our process, it’s part of quality care. Any recommendations from such reviews, we coordinate with the GP to implement.
• Internal Quality Reports: The manager compiles regular reports (monthly or quarterly) that include medication management metrics:
  • Number of medication errors this period (and brief descriptions).
  • Number of missed doses (with reasons like refused, etc.).
  • Training updates (e.g., “95% of staff have current medication training, 2 staff are scheduled for refresher next week”).
  • Results of audits (e.g., “MAR audit for March showed 98% compliance, with 3 minor documentation errors being addressed with individuals”).
  • Any improvement initiatives (e.g., “Introduced new MAR cover sheet listing allergies in bold font”).

These reports are reviewed by higher management and also used at inspection feedback.

• Continuous Improvement: When audits or feedback identify areas for improvement, we develop an action plan. For example, an audit might show that documentation of PRN effectiveness is inconsistent. An action might be: retrain staff on PRN recording and introduce a simple PRN evaluation form. We then follow up next month to see if it improved. Another example: if service users express confusion about their meds, we might create easy-read medication information leaflets for them at home, and audit if that’s being used.
• Compliance with Regulatory Expectations: We use the Care Inspectorate’s quality framework and guidance as a reference to ensure our audits cover what inspectors would look for. For instance, the Care Inspectorate’s guidance template (2012) lists key areas which we mirror in our policy and thus in our audits: storage, administration, recording, etc., all have to be covered. By internally checking these, we aim to have “no surprises” when an inspection happens.
• Care Inspectorate Inspections: During an inspection, if the Care Inspectorate examines our medication management:
  • We provide them with our medication policy (this document) to show our framework.
  • We show training records to prove staff are trained.
  • We may demonstrate the eMAR system and how we audit it.
  • We have ready the logs of incidents and audits. Inspectors typically appreciate when a service can show “Here’s an error we had, here’s what we did, and here’s how we learned from it” – it shows a proactive approach.
  • If the Inspectorate makes any recommendations or requirements (for example, a recommendation to improve how we record self-administered medications in care plans), we will create an action plan to implement those changes promptly. Management will address each item, assign responsibility, and set a timeframe, then inform the Inspectorate once completed.
• Documentation Retention: As part of QA, we ensure that all medication records are kept for the required duration. Currently, best practice is to keep adult care records (including MAR charts) for a number of years (in case of future queries or legal issues). We have an archiving process for eMAR data and any paper records to comply with these retention guidelines.
• Service User Outcomes: Ultimately, our QA looks at outcomes like: are service users healthy and stable on their medications? Are they experiencing fewer medication-related problems? We might track hospital admissions related to medication (e.g., did anyone go to hospital due to taking meds incorrectly – hopefully not if we are doing well). The qualitative feedback from service users (“I always get my pills on time and I understand what they’re for”) is as important as the quantitative audit results.

Through these audit and quality assurance activities, we demonstrate that our service is not only providing medication support, but also actively monitoring and improving how we do so. This continuous cycle of checking, learning, and improving ensures a high standard of care that meets regulatory requirements and, more importantly, keeps service users safe and well-supported.

References & Guidance: This policy is informed by the Care Inspectorate’s guidance on medication in care settings, including Prompting, Assisting and Administration of Medication, the Care Inspectorate’s Review of Medicine Management Procedures Template for care at home, and the Health and Social Care Standards (2018). It also adheres to SSSC Codes of Practice and incorporates relevant legislation such as the Adults with Incapacity (Scotland) Act 2000 for consent to treatment. All staff are expected to follow this policy, and any updates to national guidance or standards will be reflected in revisions of this document. Through adherence to these guidelines, our service ensures that individuals receive their medication safely, effectively, and in a manner that upholds their rights and dignity, meeting the high standards expected by the Care Inspectorate and SSSC.

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