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S109. Medication Management in Supported Living

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Medication Management Policy

Policy Statement

Most people receiving care in their own homes or supported living are prescribed some form of medication at some time as part of their treatment by their doctor or nurse and many have multiple medication needs.

While many people using services manage their medication effectively themselves with the appropriate support from their informal carers, some ask for or need support with their medicines from their social care provider, as reflected in their needs assessment and care plans, and local commissioning agreements. Their needs will range from simple reminders and help with packaging through to actual administration of medication.

In some cases, this might include the administration of “controlled” drugs, which requires care workers to know how they are being safely stored and administered in the home setting.

{{org_field_name}} recognises that the correct and effective administration of medication is essential for the safety and wellbeing of the people using its services. People must, therefore, receive the help identified in their care plan for the administration of medication only by trained and competent staff.

{{org_field_name}} supports the NHS STOMP initiative in respect of the overprescription of psychotropic and other drugs to control behaviour that are often inappropriately prescribed, particularly for people with learning disabilities and autism. From its observations it will always question the prescribers about any situation where it considers there has been overprescribing that is affecting the health and wellbeing of the individual concerned.

This policy should be read and used with other related policies and procedures that address specific matters involved in the management of medication in home care, including:

This policy applies wherever the service has agreed to support a person in taking their medicines, which include prescribed and over-the-counter medicines, and those to be taken (as required).

The service allows only trained and competent care staff or registered nurses to provide any level of medicines support in line with their respective roles and responsibilities for the individual’s care and support provision.

Legislation and Guidance

{{org_field_name}}’s policies and procedures are all in line with relevant legislation and best practice guidance relating to the management and administration of medication in adult social care, including:

CQC Fundamental Standards Compliance

The service’s medication policies should comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Regarding medication, Regulation 12: Safe Care and Treatment includes a requirement for the “proper and safe” management of medicines and for sufficient medicines to be made available to meet people’s needs and ensure their safety.

Guidance accompanying the regulations states that, where a care service supports the management of medication:

• the provider must provide care and treatment, including medication management, in a safe way
• care and treatment assessments, planning and delivery (including those related to medication and when people start to use the service, are admitted, discharged/transferred or move between services):
a) should be based on risk assessments that balance people’s needs and safety with their rights and preferences
b) should include arrangements to respond appropriately and in a timely manner to people’s changing needs
c) where appropriate, should be carried out in accordance with the Mental Capacity Act 2005
• medication reviews should be part of, and align with, people’s care and treatment assessments, plans or pathways and are completed and reviewed regularly in relation to changes in medication
• the provider should comply with relevant Patient Safety Alerts, recalls and rapid response reports issued from the Medicines and Healthcare products Regulatory Agency (MHRA) and through the Central Alerting System (CAS)
• arrangements should be in place to ensure the provider can take appropriate action in the event of a clinical/medical emergency
• the administration of medications should be timely to ensure that people are not placed at risk, particularly as a result of any non-concordance (non-adherence or non-compliance) by the person receiving care
• any arrangements for giving medicines covertly, where this is thought to be in the person’s best interests, should be in line with the Mental Capacity Act 2005
• staff responsible for medicines management and administration should be suitably trained and competent. They should work only within the scope of their qualifications, competence, skills and experience (including when administering medication). This is particularly important when the person has been prescribed “controlled drugs” the administration of which the agency has agreed to have a role, as determined by the care plan.

The CQC have supported regulation by publishing an online resource, Medicines Information for Adult Social Care Services. Updated in May 2022, the resource provides links to a range of webpages providing information and guidance. Relevant guidance to take note of includes Medicines Administration Records in Adult Social Care and Multi-compartment Compliance Aids (MCAs) in Adult Social Care.

Procedures

Principles of Safe Medicines Management

The service follows the rules of safe medicines management that are provided in NICE guidelines ensuring that its care staff observe the “6 R’s” of safe medicines administration:

Medication Management Principles

When providing care to adults, care staff are expected to follow these principles and procedures.

Person-centred principles

  1. Every person using care services has the right to manage and administer their own medication if they wish to and the agency recognises this by providing support to enable safe self-administration wherever possible. Encouraging self-medication promotes the independence and autonomy of people using the services and will enhance their dignity and privacy.
  2. However, some people may not wish to manage their own medication and others may be unable to even if they wish.
  3. The choices made by people — eg to administer and manage their own medication — are always respected by staff and recorded in the plan of care.
  4. No assumption is made that someone cannot self-administer their medication purely on the basis of their condition or mental capacity.
  5. People who are suspected to be lacking capacity are assessed in line with the “best interest” principles of the Mental Capacity Act 2005. Where a person can be enabled to self-medicate with additional support, or where they can self-administer parts of their medication, such support is provided.
  6. Staff provide appropriate support to any person who wishes and is able to take all or some of their own medication.
  7. Medication is only ever administered to someone on the basis of their explicit consent or agreement to take the medication except where “best interests” decisions have been taken as a result of a person’s mental incapacity.

Agreements made

  1. All new people to the service will have their health and social care needs fully assessed and any need for help with the collection or administration of medication identified. This will often be done jointly with healthcare professionals who might also be providing care and support.
  2. Any request for support from staff identified within a care plan is discussed with managers or nurse consultants (either employed by the agency or health services) before being implemented to ensure that the role being requested is appropriate and can be performed safely and competently by the agency’s care workers.
  3. The service will always work in partnership with the health services and professionals also involved with the people using its services, and the local authority where involved as commissioners and regarding any safeguarding issues.
  4. No staff member should proceed with the administration of medicines (including tablets, liquids and creams) unless they have the explicit agreement of the person and their nurse consultant or manager and this has been entered in the plan of care.
  5. Any staff member who is unsure of what to do regarding medication in any given situation should contact their nurse consultant or manager immediately. In all cases where help with medication is required, the explicit consent of the person is required.
  6. Care staff proving medicines support should always ensure that any medication being taken is fit for purpose and safe to administer by following the “6 R’s” described above, and always checking that it has been stored securely, at the correct temperatures, and the contents have not been tampered with.

Medication Reconciliation (Listing of Medicines)

To ensure that the agency contributes fully and effectively, as and when required, to the safe taking of their medicines, the agency will carry out the following “medicines reconciliation” procedures in co-operation with the other professionals and services involved.

The agency will always ensure that it has the following information prior to any involvement, and keeps it up to date. This information will be particularly important where people have been prescribed “controlled drugs” and where the person has been unable to give their consent to the taking of their medicines, resulting in “best interest” decisions being taken about the prescribing, supplying, storing and taking of their medication.

Medicines-related Safeguarding

{{org_field_name}} considers that the safety and safeguarding of the people receiving care is paramount. This includes safety from any misuse of medicines by its staff or errors in medicine administration. The service will take all possible action to safeguard its users from such risks, including by explicitly linking its medicines management safeguards with its wider safeguarding of adults’ processes.

Care workers, when responsible for people’s medicines, are instructed to report and record to the service management all medicines-related incidents, including errors, “near misses” and incidents that might represent a safeguarding risk. Where necessary, these should be reported to the regulator and to local safeguarding authorities.

Immediately after the discovery of any medicines-related safeguarding incident, the service will contact an appropriate health professional to check that suitable action has been taken to protect the health and wellbeing of anyone involved — this will usually be the GP.

The service will include the investigation of all medicines incidents in its wider safeguarding and governance processes, establishing root causes of incidents and monitoring reports for trends. Lessons learnt will be included in a review of the service’s medicines policies and processes, including training for staff.

People using services and/or their family members or carers will be provided with full information about any medicines-related safeguarding incidents caused by the practices of {{org_field_name}}, and about the progress of any investigation. Where indicated it will comply with its duty of candour by issuing a formal apology.

People and/or their family members or carers are provided with full information on how to complain about or to report a medicines-related safety incident or any concerns about the service’s medication procedures.

(See also separate Drug/Medicines Errors (Identifying, Reporting and Reviewing Medicines-related Problems) Policy.)

Pro re nata (PRN) medication

Background

Most medication is prescribed or bought with clear instructions of how much should be taken and how often.

However, some medication is prescribed on a “taken as required” dose, sometimes abbreviated as PRN (pro re nata). “To be taken as required” means medication to be taken when needed, eg when a person is in pain. Some non-prescribed medication, which might be bought “over the counter” such as paracetamol can also be taken as required within certain limits depending on the reasons for its use.

PRN medication is usually prescribed to treat short-term or intermittent medical conditions and is not to be taken regularly. Painkillers are commonly prescribed on a PRN basis or obtained on an over-the-counter basis.

PRN medicines are those that do not have prescription regimes concerning the times and amounts to be taken on each occasion, but are to be used when the need arises. They include medicines described as “Emergency Use” or “Rescue” medicines, the use of which should follow common principles of medicines administration applied to particular conditions and circumstances.

All such medication will usually have on its patient information leaflet the limits in which it can be safely used, in terms of amounts and frequency, and whether it might interact adversely with other medication being taken. This information must always be studied and observed by the user and others involved in its administration.

All users of PRN medicines including emergency use and recue medicines should closely follow all medical and pharmaceutical advice to understand their purpose and under what circumstances a particular medicine might be used.

In a home care situation, the service’s care workers are not present 24 hours a day. Thus, with prescribed medicine to be “taken as required”, including any emergency use or rescue medicines provided or with any “over-the-counter” medicines bought by the person or their informal carers, staff may not always be available to help or observe the taking of any such medicines.

To ensure there is no conflict with any other medicines that they are responsible for giving, it is essential, therefore, that staff are kept informed and keep themselves informed of when these medicines are being taken and the doses involved.

Procedures

{{org_field_name}} always checks if the person has been prescribed any PRN medicines, including “rescue” or “emergency use” medicines, or is taking any “bought over-the-counter medicines”.

If yes, carers should continue to check routinely if the person has been taking any of these medicines between visits. They should also do this before agreeing to give any PRN medicines that they are asked to give, eg because the user is in pain at the time.

To ensure all PRN medication is given and taken as intended, there should be a specific plan for administration in the person’s care plan, which can be kept with the MAR charts. This will state clearly what the medication is for and the circumstances in which it might be given.

For example, a person who has been prescribed a PRN anti-emetic will have an entry to state that the medication is used to treat nausea or vomiting. If requested to help with the giving of the medicine, or it is evidently needed at the time, visiting care staff must always assess any risks to the medication being given safely. In doing so, it is always important to check with the person what their needs and wishes are.

People and their informal carers might be encouraged to keep a record of the occasions when they have taken any PRN and emergency medicines, but visiting carers should always check verbally as well as noting what has been recorded.

Carers should always be aware that PRN medication might not only be taken on set occasions, but whenever the person requires it, ie whenever they are experiencing symptoms. The checking therefore will also yield information about the person’s wellbeing, and if there are indications that the person’s health is deteriorating, appropriate action should be taken.

Visiting carers should clearly record all medicines that they have given on the medicines’ chart, including any PRN and emergency use medicines, and note the use of any PRN medicines that have been reported to them. They should report any concerns about their use to their supervisor/manager.

When PRN medication is being given on a regular or increasing basis or the person appears to be at risk of being dependent on it, the service might recommend a review of its use. For instance, if a person is taking painkillers more often than formerly this might signal a change in their medical condition. Alternatively, where PRN is no longer required it may need to be discontinued.

PRN medicines should always be provided in their original packaging complete with label and clear instructions for use.

{{org_field_name}} monitors and regularly reviews the usage of PRN and emergency use medication in the situations in which it is involved to make sure that it is following current best practice pharmaceutical guidance.

Common Procedures for PRN and Emergency Use/Rescue Medicines

The following procedures provide a common framework for the drawing up of individual PRN care plans and emergency medicines/ protocols suitably adapted to the home care situation and the care services’ responsibilities for their safe administration.

Any PRN or emergency use medicine that has been prescribed or recommended on medical advice should be clearly recorded in the person’s care plan with information on why its use has been authorised.

The care plan should include information on:

– why the medicine has been prescribed or made available “as required” /for emergency use

– how it is being used in relation to any responsibilities the care service has for a user’s medicines

– whether the care service should be involved in any way with its use (because it might be needed when a service is not being provided) and how

– the mode and route of administration eg tablets or liquid, inhaler, or injector with clear instructions on each

– the recommended dose to be taken at any one time, including any repeats

– the minimum time between doses allowable in line with the prescribing instructions/PIL

– the maximum number of doses to be taken in a set period, eg 24 hours

– how the person usually takes the medicine i.e. can self – administer/needs support or administration by carers/others

– the required competence of the person to self – administer and of any staff/third party to support or administer the medicines and any instruction/training provided

– any difficulties/issues that the person might have in taking the medicine, eg with injections or use of aids like drivers and how they should be addressed if arising

– whether the medicine is safe to use at the time that it is requested/needed (eg will not conflict with any other medicines being taken at the time)

– how any administration is being recorded

– instructions on any follow up actions eg when to call for emergency medical help and guidance

– instructions on how any adverse incident arising from its use should be reported and will be dealt with.

Help for People to Take Their Medication

a) reminder charts
b) winged bottle caps
c) large print labels
d) alarms (such as notifications on mobile phones)
e) tablet splitters
f) eye drop aids
g) inhaler aids
h) audible alarms
i) monitored dosage systems (MDS) or multi-compartment compliance aids (MCAs)
j) telehealth aids, etc.

Care Worker Roles in Medication Support

{{org_field_name}} recognises the different kinds of support that can be provided for people who have identified needs in handling their medication.

Providing general support

General support can include:

The policy is always to:

Assistance with administration of medication

Any need for medication to be actually administered by staff is identified at the care assessment stage and recorded in the individual care and support plan. The person must agree to have the care worker administer the medication and the consent is also documented. If the person is unable to communicate informed consent, the prescriber must indicate formally that the treatment is in the best interest of the individual and comply with the requirements of the Mental Capacity Act.

Medication is only ever administered by a designated, appropriately trained member of staff.

When administering medication staff always:

A Home Care Medicines Record (or MAR) is kept in the home of anyone receiving help with medication as part of their care plan.

Any mistake or error in administering drugs must be reported to a parent (in the case of a child), line manager, supervisor or responsible medical practitioner without delay.

Staff must never in any circumstances administer medication that has not been prescribed, give medication to a person against their wishes, give medication that has been prescribed to another person, or alter in any way the timing or dosage of medications.

If a care worker does not feel competent to administer the medication they should voice their concerns to their line manager. It is important that only staff who are appropriately trained and agree to perform the role administer medication.

Application of Transdermal Patches

Procedure for Applying Patches:

Wash hands thoroughly before and after application.
Wear disposable gloves during the application process.
Remove the old patch before applying a new one.


Use of Body Maps:

Utilise body maps to document the site of each patch application.
Rotate application sites to prevent skin irritation and ensure consistent absorption.
Avoid applying patches to broken, irritated, or scarred skin.

Recording Application Details:

Document the date, time, and site of application on the MAR chart and body map.
Note any observations such as skin reactions or patch integrity.

Specialised administration

In exceptional circumstances and following an assessment by a healthcare professional, a care worker may be asked to administer medication by a specialist technique including:

Any care worker asked to carry out any such procedure must agree to doing so and be properly trained in that procedure with specialist supervision also provided. All procedures must be recorded on a MAR.

Medicines Records

In line with the NICE guidelines (NG67), the agency will keep a separate record within the care plan for all medicines support it provides. The agency ensures through its monitoring and auditing arrangements that the medicines records like the other care records are accurate and kept up to date, and accessible in line with the person’s expectations for confidentiality.

Care workers must record on the appropriate medical administration record chart or in some cases medicines’ support section of the care plan, the medicines support given on every occasion together with any other relevant information.

Recording should include details of all the support provided for prescribed and over-the-counter medicines, such as:

If the agency’s care workers are responsible for giving any medicines, they are expected to record their actions on a medicines administration record such as one obtained from the supplying pharmacist, or the agency’s own, produced to enable all required information to be recorded.

All medicines administration records used will include:

According to Medicines Administration Records in Adult Social Care, published in May 2022 by CQC, home care workers should make a record each time they provide medicines support. This must be for each individual medicine on every occasion.

The CQC specifies that both paper-based or electronic medicines administration records must:

The agency will work with family members and informal carers to ensure recording can be as complete as possible. Care staff are required to always check if medicines have been correctly taken at times other than when they are giving them, and to report any concerns.

Monitoring of Medication

Staff should always be aware of the nature of the medication being taken by individuals and should report any change in condition that might be due to medication or side effects immediately to a family member/ Next Of Kin, their line manager or supervisor, or to the GP or community pharmacist.

The agency will work closely with community pharmacy services and with people’s GPs to ensure that they are provided with adequate support and a seamless and integrated service relating to their medication needs, sharing all relevant information on a need-to-know basis with due regard given to confidentiality of the person receiving care.

Non-compliance with Medication

{{org_field_name}} accepts that there are circumstances whereby some people will fail to comply with their prescribed treatments. This might include self-medicating people failing to take their medication as directed or non-self-medicating people refusing their prescribed medication, or failing to swallow it and then disposing of it.

In such cases, the service is clear that its staff have no right to force non-compliant people to take their medication, but that staff do have a duty to refer all such occurrences back to the original prescriber, to the person’s GP and/or to the person’s nurse or key worker. (See separate Non-compliance with Medication in Care Policy.)

Ordering, Storing, Transporting and Disposal of Medicines

This policy applies where a supported living care service accepts responsibility for ordering, storing, transporting and/or disposing of a service user’s medicines. It is produced in line with the guidelines produced by the National Institute for Health and Care Excellence (NICE):

The policy should be used in relation to other medicines support policies (also based on NICE guidance) for supported living care, including:

Ordering Medicines (Where Applicable)

In exceptional cases, {{org_field_name}} might be asked to order medicines for a service user. In which case, {{org_field_name}} will follow NICE (2017) guidance as follows.

Storing of Medicines (Where Applicable)

Where {{org_field_name}} agrees to support a service user with their medicines, it will always ensure that the medicines are kept safe and securely stored in the person’s home, working in partnership with all involved to achieve this.

If a person is at risk because of unsecured access to their medicines (thereby also making it more difficult for {{org_field_name}} to provide safe medicines support), care providers should agree with the person and/or their family members or carers if secure home storage is needed, for example, a lockable cupboard with access restricted only to those who need to have it.

This is particularly important if the user is prescribed controlled drugs.

With some medicines fridge storage might be needed with some monitoring of the fridge and ambient temperatures built into the care plan.

Care workers responsible for providing medicines’ support must always report and seek professional advice if they find that the medicines are being incorrectly stored.

Transporting of Medicines (Where Applicable)

Most medicines will be kept in the person’s home, and if it has been agreed that care workers should collect prescriptions (in line with the Prescriptions Collection Policy) they will usually leave them at the person’s home for safe keeping.

{{org_field_name}} will carry out a risk assessment before agreeing to its staff being involved in any transporting of a person’s medicines.

Disposal of Medicines (Where Applicable)

If {{org_field_name}} agrees to the disposal of any unwanted, damaged, out-of-date or part-used medicines on behalf of the service user, it will first obtain agreement from the person (or their family member or carer) on how the medicines should be safely disposed of.

The procedures should be in line with local policies, which are usually to return them to a pharmacy for safe disposal with special considerations given for the disposal of controlled drugs, needles and syringes, which also in line with local procedures could involve using a licensed waste disposal service.

{{org_field_name}} will consult local pharmacists, health professionals and the local authority waste disposal service over the correct procedures for any specific products.

{{org_field_name}} will keep a record of the actions taken, including the name and quantity of medicine, the name of the person returning the medicine, the date returned and the name of the pharmacy to which the medicines have been returned.

Hand Hygiene and Use of Gloves During Medication Administration

To ensure the safety of both service users and staff, it is essential to adhere to strict infection control practices during the administration of medications. Proper hand hygiene and the appropriate use of personal protective equipment (PPE) are critical components in preventing the spread of infection and reducing the risk of accidental exposure to medications.

Hand Washing:

Staff must wash their hands thoroughly with soap and water before and after administering any medication.
Hand washing should last at least 20 seconds, covering all areas of the hands and wrists.
In situations where soap and water are not available, an alcohol-based hand sanitizer with at least 60% alcohol content should be used.
Hand hygiene is crucial even when gloves are worn, as gloves can have microscopic tears or may become contaminated during removal.


Use of Gloves:

Disposable gloves must be worn when there is a risk of direct contact with medications, bodily fluids, or when applying topical medications such as creams, ointments, or transdermal patches.
Gloves should be donned immediately before the task and removed immediately after, followed by hand hygiene.
Do not reuse gloves or wear the same gloves for multiple tasks or between different service users.
Wearing gloves does not replace the need for proper hand washing.

Actions Following Medication Errors Involving Staff Responsibility

In the event of a medication error where a member of staff is responsible, the following actions will be undertaken by {{org_field_name}} to ensure the safety of service users and to maintain high standards of care:

Immediate Response:

Provide necessary medical attention to the affected service user.
Report the error immediately to the supervising manager or designated person in charge.


Investigation and Documentation:

{{org_field_name}} will:

– conduct a thorough investigation to determine the cause of the error.
– ocument all details of the incident accurately in the incident reporting system.
– reserve any evidence that may assist in the investigation.


Review of Staff Competencies:

– assess the competency of the staff member involved in the error.
– identify any knowledge or skill gaps that may have contributed to the incident.
– schedule a one-on-one meeting to discuss the findings and areas for improvement.


Retraining and Support:

– provide targeted retraining sessions to address specific areas of concern.
– offer additional supervision or mentoring if necessary.
– set clear expectations and timelines for improvement.


Disciplinary Action:

– if the error resulted from negligence, non-compliance with policies, or misconduct, initiate appropriate disciplinary procedures in line with the organisation’s disciplinary policy.
– actions may include written warnings, suspension, or termination of employment, depending on the severity and circumstances of the error.


Reporting to External Agencies:

Local Authority Safeguarding Team:
Medication errors that result in significant harm, potential harm, or abuse must be reported to the local authority safeguarding team.
Examples include administering the wrong medication, overdoses, or repeated errors by the same staff member.
Reporting must be done promptly and in accordance with local safeguarding protocols.
Regulatory Bodies:
Notify the Care Quality Commission (CQC) and the local authority safeguarding team as required.

Local Safeguarding details:

{{org_field_local_authority_authority_name}}

{{org_field_local_authority_information_link}}
Ensure compliance with statutory notification requirements.


Communication with Service Users and Families:

Inform the affected service user and, where appropriate, their family or advocate about the error.
Provide honest and transparent information regarding the incident and the steps being taken to prevent recurrence.
Offer apologies and discuss any concerns they may have.

Preventative Measures:

Review and, if necessary, update medication administration policies and procedures.
Share lessons learned from the incident with the wider team to prevent similar errors.
Implement additional safety measures such as double-checking processes or technology solutions.

Monitoring and Follow-Up:

Monitor the staff member’s performance following retraining to ensure compliance and improvement.
Schedule follow-up competency assessments.
Maintain open communication channels for staff to express concerns or seek guidance.

Training

In this agency:

Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}

Reviewed on: {{last_update_date}}

Next Review Date: {{next_review_date}}

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