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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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Medication Administration and Management Policy

1. Purpose

The purpose of this Medication Administration and Management Policy is to ensure that all temporary workers employed by {{org_field_name}}, including registered nurses (RNs) and healthcare assistants (HCAs), administer and manage medications safely, effectively, and in accordance with legal and professional requirements. Medication management is a critical component of safe and effective healthcare, especially when providing services to vulnerable adults and older people in care homes and residential settings. This policy aims to protect the health, safety, and wellbeing of service users, promote good practice, comply with English legislation, and provide clear guidance to temporary workers, client organisations, and regulatory bodies. {{org_field_name}} recognises its responsibilities as a temporary staffing agency to ensure that workers supplied by it are recruited, trained, supported and monitored so far as is reasonably practicable for safe medicines practice. This policy is informed by the Medicines Act 1968, the Human Medicines Regulations 2012, the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations 2001, the Mental Capacity Act 2005, the Health and Safety at Work etc. Act 1974, the Data Protection Act 2018 and UK GDPR, relevant NICE guidance including SC1 Managing medicines in care homes, and the professional requirements of the Nursing and Midwifery Council (NMC). Where temporary workers are supplied to a client that is itself a regulated provider, that client remains responsible for its own regulated activity obligations, local medicines systems, care planning, MAR/eMAR processes, storage arrangements and provider-level governance. This policy also outlines how the director will effectively manage, monitor, and improve medication-related practices within the organisation.

2. Scope

This policy applies to:

• All temporary workers, including registered nurses and healthcare assistants, employed by {{org_field_name}} under zero-hours or casual contracts
• All care settings where temporary workers are placed, including nursing homes, residential care homes, and healthcare facilities
• Directors, office staff, and any other personnel involved in coordinating placements or providing support to temporary workers This policy does not replace the policies and procedures of client organisations. Temporary workers must also adhere to the medication policies of the service where they are working.

For the avoidance of doubt, {{org_field_name}} supplies temporary workers to client organisations and does not, by virtue of this policy alone, assume responsibility for carrying on any regulated activity of the client. The client organisation remains responsible for service-user-specific medicines assessments, prescribing arrangements, local authorisation to administer medicines, medicines storage systems, MAR/eMAR records, controlled drugs governance, care plans, and any provider obligations under CQC regulations. {{org_field_name}} is responsible for safer recruitment, verification of qualifications and registration, baseline training and competence records, and responding appropriately to incidents, concerns or allegations involving workers supplied by it.

3. Related Policies

• Code of Conduct for Temporary Workers
• Safeguarding Adults and Children Policy
• Health and Safety Policy
• Incident Reporting and Management Policy
• Record Keeping and Confidentiality Policy
• Complaints Policy
• Disciplinary Policy
• Safer Recruitment and Pre-Placement Checks Policy
• Right to Work Checks Policy
• DBS and Safeguarding Checks Policy
• Agency Worker Terms, Pay and Key Information Document Policy
• Data Protection and Information Governance Policy
• Modern Slavery and Labour Exploitation Policy

4. Legal and Professional Framework

All temporary workers supplied by {{org_field_name}} and all staff involved in recruitment, deployment and oversight of such workers must comply with the legal and professional requirements relevant to their role, including where applicable:

• the Medicines Act 1968;
• the Human Medicines Regulations 2012;
• the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations 2001;
• the Mental Capacity Act 2005;
• the Health and Safety at Work etc. Act 1974;
• the Data Protection Act 2018 and UK GDPR;
• NICE guideline SC1: Managing medicines in care homes, together with other current NICE medicines-management guidance relevant to the placement setting;
• the NMC Code and any current NMC standards, guidance and supplementary information applicable to registered nurses, nursing associates or nurse prescribers;
• the Royal Pharmaceutical Society guidance, where relevant; and
• the written medicines policies, procedures, care plans, risk assessments and local authorisation arrangements of the client organisation.

Where the client organisation is a regulated provider, that provider remains responsible for compliance with provider-level obligations under the Health and Social Care Act 2008 and associated regulations. {{org_field_name}} does not provide regulated care merely by supplying staff, unless it separately carries on a regulated activity.

5. Medication Administration Principles

5.1 Responsibilities of Temporary Workers

All temporary workers must:

• Only administer medication if they have received appropriate training and are deemed competent by both {{org_field_name}} and the client organisation
• Work within their role boundaries, skills, and competence
• Follow the “Five Rights” of medication administration: the right person, the right drug, the right dose, the right route, and the right time
• Check for allergies, contraindications, and previous adverse reactions before administering any medication
• Document administration accurately and contemporaneously in the appropriate records
• Check the original prescription, MAR/eMAR entry, allergy status, route, formulation, expiry date and any service-user-specific instructions before administration.
• Follow the client’s local policy for omitted doses, PRN medicines, variable-dose medicines, transdermal patches, covert administration, self-administration, refrigeration, controlled drugs and medicines reconciliation.
• Escalate immediately to the client’s nurse in charge, manager, prescriber, pharmacist or other appropriate clinician where there is any discrepancy, unclear instruction, omitted signature, stock discrepancy, unexpected refusal, adverse reaction or concern about capacity, consent or best interests.
• Immediately report and record medication errors, near misses, or concerns following both {{org_field_name}}’s Incident Reporting and Management Policy and the client’s procedures
• Seek guidance from a registered nurse or responsible clinician if uncertain

Unregistered workers, including healthcare assistants, may only undertake medicines-related tasks where this is permitted by law, the client organisation’s policy, the placement setting, and their own training and assessed competence. They must only do so following appropriate delegation, local induction and authorisation, and within clearly defined role boundaries. They must not undertake any medicines-related task for which they have not been trained, assessed as competent and authorised. Registered professionals remain accountable for any delegation they make, and all workers remain accountable for accepting only those tasks they are competent to perform safely.

5.2 Types of Medications Covered

This policy applies to:

• Prescription-only medicines (POMs)
• Controlled drugs (CDs) under the Misuse of Drugs Act 1971
• Pharmacy medicines (P)
• Over-the-counter medications
• Homely remedies as per the client’s protocol

Temporary workers must comply with the client’s homely remedies protocol where applicable and never administer medications without prior authorisation.

5.3 Delegation, Local Induction and Client Authorisation

Before any worker administers or supports with medicines in a placement, the client organisation must have confirmed the worker’s local induction, access to relevant medicines policies, and any setting-specific authorisation required by the client. {{org_field_name}} will verify baseline recruitment, registration, training and competence records, but the client remains responsible for confirming that the worker is suitable and authorised for the particular role, service user group, medicine systems and tasks in that placement. If there is any doubt about local authorisation or competence, the worker must not proceed and must escalate immediately.

6. Medication Storage and Security

Temporary workers must:

• Ensure that all medications are stored securely following the client organisation’s procedures
• Follow all instructions regarding the safe storage of controlled drugs, including use of locked controlled drug cupboards
• Never leave medication unattended, unsecured, or accessible to unauthorised persons
• Report any discrepancies or concerns regarding medication storage immediately

Temporary workers must use and secure medication trolleys, cupboards, fridges and keys in accordance with the client organisation’s procedures while they are in their charge and must report immediately any loss of keys, temperature concern, stock discrepancy, unauthorised access or other medicines-security issue.

7. Controlled Drugs

Temporary workers must:

• Handle controlled drugs with extreme care and follow all legal requirements under the Misuse of Drugs Regulations 2001
• Follow all legal requirements and the client organisation’s controlled drugs procedures, including any requirement for witnessing, checking, recording, storage, destruction, discrepancy reporting and escalation to the appropriate senior clinician, manager or controlled drugs accountable arrangements.
• Accurately record controlled drug administration in the client’s controlled drug register
• Promptly report any discrepancies, suspected diversion, or incidents involving controlled drugs to both {{org_field_name}} and the client

8. Consent and Capacity

Temporary workers must:

• Obtain valid consent prior to administering any medication in line with the Mental Capacity Act 2005
• Respect the service user’s right to refuse medication, documenting and reporting all refusals according to the client’s procedure
• Seek advice from the client’s senior staff or healthcare professional when a service user lacks capacity to consent
• Follow best interest decision-making processes when administering medication to people lacking capacity

Medicines must not be administered covertly unless this has been agreed in accordance with the Mental Capacity Act 2005, following an assessment of capacity and a properly documented best interests decision, with a clear management plan that specifies the medicine, the method of administration, how safety and effectiveness will be reviewed, and when the arrangement will be reconsidered. Temporary workers must never initiate covert administration on their own authority and must follow the client organisation’s current covert medicines procedure.

8.1 Self-Administration of Medicines

Where the client organisation supports a service user to self-administer medicines, temporary workers must follow the client’s risk assessment, care plan and local procedure. Workers must support self-administration where this is permitted and safe, must not remove a person’s independence without authority, and must report any concern about capacity, adherence, deterioration, stock control or risk to the client organisation immediately.

9. Record Keeping

Temporary workers must:

• Maintain accurate, clear, and contemporaneous records of all medications administered, omitted, refused, or wasted
• Ensure that all entries are signed, dated, and, where applicable, countersigned as required (e.g., for controlled drugs)
• Report and document any medication errors, omissions, or incidents immediately
• Maintain confidentiality, information security and lawful data handling in accordance with UK GDPR, the Data Protection Act 2018, the client organisation’s confidentiality arrangements, and any additional rules governing special category data such as health information, medicines records and criminal records information.

Records must include the service user’s name, the name and dose of the medication, the time of administration, the route, and any relevant observations. Entries must be made on the client’s approved MAR/eMAR or other authorised record, must be clear, attributable and contemporaneous, and must include the reason for any omission, refusal, delay, variable dose, PRN administration, wastage or discrepancy, together with any escalation taken.

10. Training and Competence

{{org_field_name}} will:

• Provide all temporary workers involved in medication administration with appropriate training, including initial induction and regular refresher training
• Verify competency through documented assessments before allowing workers to undertake medication-related tasks
• Record all completed training and competency assessments in the worker’s file
• Support client organisations to verify and confirm the competency of temporary workers assigned to them

Temporary workers who fail to complete or maintain required medication training will not be assigned to roles requiring medication administration.

Competence assessment must include, where relevant to the role, direct observation of practice, review of medicines knowledge, checking of registration status where applicable, and confirmation that any specialist task has been specifically trained and assessed. Refresher training and competence review must take place at regular intervals and at least annually where medicines support forms part of the worker’s role, or sooner where there has been an incident, complaint, change in duties, change in legislation or guidance, or concern about competence.

11. Medication Errors and Incident Reporting

The immediate priority following any medicines incident is the safety of the service user. Temporary workers must take prompt steps to protect the person, obtain urgent clinical advice where required, inform the client organisation without delay, and then notify {{org_field_name}} in accordance with internal reporting requirements.

Temporary workers must:

• Immediately report any medication error, near miss, or incident to the client organisation and {{org_field_name}}
• Follow the procedures outlined in the Incident Reporting and Management Policy
• Participate fully in any investigation into medication errors
• Reflect on incidents as part of continuing professional development and learning

Directors will ensure that lessons learnt from incidents are incorporated into training and shared with client organisations where appropriate.

12. Director’s Responsibilities and Oversight

As {{org_field_name}} is a temporary staffing agency and not a CQC-registered provider of regulated activities unless expressly stated otherwise, overall responsibility for this policy rests with the director or other nominated senior lead.

The director will:

• Ensure that this policy is reviewed annually or earlier if there are changes in legislation, guidance, or best practice
• Ensure that baseline medicines training, professional registration checks where relevant, and competence records are obtained and reviewed by {{org_field_name}}, and that workers are only supplied to placements appropriate to their role, training and verified competence.
• Review all medication-related incidents, complaints, and audits to identify trends and areas for improvement
• Liaise with client organisations regarding worker performance and compliance with medication procedures
• Act immediately where there are concerns about a worker’s competence, including removing them from assignments if necessary
• Foster a culture of openness, safety, and learning regarding medication administration
• Ensure that the agency’s medicines policy is aligned with its safer recruitment, right-to-work, DBS/safeguarding, data protection and agency worker compliance arrangements, and that concerns are escalated to the client organisation, professional regulator, local authority, police, DBS or other authority where legally required.

13. Working with Clients

{{org_field_name}} will:

• Ensure that all temporary workers adhere to the medication policies of client organisations
• Obtain from the client organisation confirmation of local induction expectations, medicines authorisation requirements, reporting routes, and any service-user-group or setting-specific restrictions before placing a worker into a medicines-related role.
• Cooperate fully with client audits, investigations, and regulatory inspections concerning medication practices
• Communicate any changes to medication-related policies, training, or legislation to client organisations
• Support clients in identifying and resolving medication-related concerns

14. Safe Disposal of Medicines

Temporary workers must:

• Follow client procedures for the safe disposal of expired, damaged, or wasted medicines
• Never dispose of medicines without appropriate authorisation
• Document disposal processes in line with client and regulatory requirements

15. Continuous Improvement

The director will:

• Review this policy annually or when necessary due to changes in law or best practice
• Engage in regular consultation with clients, temporary workers, and external stakeholders
• Seek feedback from incidents, audits, and inspections to drive improvement
• Ensure training materials and processes are updated regularly to reflect current standards

15.1 Interface with Agency Compliance Obligations

This policy must be read alongside {{org_field_name}}’s wider legal and compliance framework for operating as a temporary staffing agency in England. That wider framework includes, where applicable, the Employment Agencies Act 1973, the Conduct of Employment Agencies and Employment Businesses Regulations 2003, the Agency Workers Regulations 2010, the Equality Act 2010, the Employment Rights Act 1996, the Working Time Regulations 1998, National Minimum Wage legislation, right-to-work requirements, safeguarding and DBS requirements, data protection legislation and modern slavery compliance. Those matters are governed primarily through separate recruitment, worker compliance and operational policies, but any issue arising under this medicines policy must be escalated and handled consistently with those wider obligations.

16. Policy Review

This policy will be reviewed at least annually or sooner if required by changes in legislation, regulatory guidance, or operational needs. The review will be undertaken by the director, who will ensure that any updates are communicated to all temporary workers and client organisations without delay.

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