Medication Management in Care Homes (Scotland) Policy

This care service recognises that the safe administration of medication is a vitally important area for service users and providers. {{org_field_name}} recognises that many service users are prescribed some form of medication and many have multiple medication needs. While some service users can, with the support, manage their medication effectively themselves, others require their medication to be managed for them.

Legislation and Guidance

This policy is written in line with the national health and social care standards, My Support, My Life, particularly Standard 2: “I am fully involved in all decisions about my care and support,” which includes as 2.23: “If I need help with medication, I am able to have as much control as possible.”

The standard states that where a service user requires help to take their medication, “it must be done safely, in accordance with the service user’s wishes, with detailed information properly recorded in the personal plan and known to the appropriate worker, planned and agreed arrangements for help with taking medication, and the relevant policies, procedures and records in place”.

The policy also helps to answer key question 1 of the Quality Framework for Older People in Care Homes, “How well do we support people’s wellbeing?”, particularly 1.3: “People’s health benefits from their care and support.”

With respect to the prescribing, supply, storage and administration of medicines, {{org_field_name}} is mindful of the need to be compliant with all relevant medicines legislation and guidance including:

Social care guideline SC1: Managing Medicines in Care Homes (March 2014), National Institute for Health and Care Excellence (NICE)
The Safe and Secure Handling of Medicines (December 2018), Royal Pharmaceutical Society
Learning from Adverse Events Through Reporting and Review: A National Framework for Scotland (2015), Healthcare Improvement Scotland
Notifications About Controlled Drugs: Guidance for Providers (2015), Care Inspectorate.

Policy Statement

This medication policy covers:

person-centred principles
ordering medicines
storage
administration and recording
disposal
medicines-related safeguarding (including medicines errors).

The policy should be read and used as part of a suite of related policies and procedures that address specific matters involved in the management of medication, all of which reflect current NICE best practice guidance. They include:

Anticipatory or “Just in Case” Medicine in Care Homes
Controlled Drugs Management in Care Homes
Covert Medication (Administering Medicines without the User’s Knowledge) in Care Homes
Domestic (Homely or Non-prescribed) Medicines in Care Homes
Drug/Medicines Errors (Identifying, Reporting and Reviewing Medicines-related Problems)
Medicine Reconciliation and Review in Care Homes
Medication to be “Taken as Required” in Care Homes
Medication when the Service User is Away from the Home
Medication Non-compliance in Care Homes
Safe Use of Oxygen in Care Homes
Pain Management
Requests for Service from GP, Other Healthcare Practitioners and/or Paramedic/Emergency Medical Services
Record Keeping for Care Homes (Scotland)
Information Governance Under the General Data Protection Regulation (England)
Confidentiality of Service Users’ Information (Scotland)
Sharing Information with Other Providers and Agencies (Care Homes) (England)
Access to Records in Care Homes (Scotland)
Transfer to, Stay in and Discharge from Hospital in Care Homes (Scotland).

Safe Medication Management Procedures

Principles of safe medicines management

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

right person
right medicine
right route
right dose
right time
right of the person to refuse.

The service also considers that giving or withholding medication should never be used as a means of control or punishment.

Person-centred principles

{{org_field_name}} works on the principle that every service user has the right to manage and administer their own medication if they wish to and provides support and aids to enable safe self-administration wherever possible. The home believes that encouraging self-medication promotes the independence and autonomy of service users and will enhance their dignity and privacy.
However, some service users may not wish to manage their own medication and others may be unable to even if they wish. Therefore, to ensure their safety, and the safety of other residents, and to ensure that adequate support can be provided, all service users must be assessed on a regular basis and will be considered for self-administration only if considered safe to do so.
Records are kept of all medication prescribed to service users who self-administer and a secure area is provided in the service user’s room for the storage of self-administered medication.
The choices made by service users — eg to administer and manage their own medication — are always respected by staff and recorded in the plan of care.
No assumption is made that a service user cannot self-administer their medication purely because of their condition or mental capacity.
Service users who are suspected to be lacking capacity are assessed in line with the requirements of the Adults with Incapacity (Scotland) Act 2000. Where a service user can be enabled to self-medicate with additional support, or where they can self-administer parts of their medication, such support is provided.
Information on a person’s current medication and likely medication needs are routinely sought on their referral and admission to the home, when a detailed list is routinely drawn up, checked and built into their plan of care (see Medicine Reconciliation and Review in Care Homes Policy).
The home will work closely with community pharmacy services and with service users’ GPs to ensure that they are provided with adequate support and a seamless and integrated service relating to their medication needs. This includes observing all local arrangements for prescribing, dispensing and ordering of medicines, repeat prescriptions, and medication reviews.
Each resident’s medication needs are regularly reviewed in consultation with the individual, GP and other professionals who need to be involved in ensuring that their medication needs are being correctly and safely met.

Ordering medicines

When ordering medicines, the home makes sure that they reach only the service users for whom they have been prescribed.
Staff responsible for ordering medicines always check that the medicines delivered to the home are in line with the prescriptions and ordering.
The home makes sure that it has at least two staff members with the training and skills to order medicines, although ordering might be done by one member of staff.
The home accepts that it is responsible for ordering medicines from the GP and does not delegate this to the supplying pharmacy.
The home makes sure that records are kept of all medicines ordered.
After medicines have been delivered, they are routinely checked against a record of the order to make sure that all medicines ordered have been prescribed and supplied correctly.

Remote prescribing

{{org_field_name}} recognises in line with NICE (2014) guidance that new or changed prescriptions obtained remotely (ie by way of telephone, video — link, or online) should only occur in exceptional circumstances. The home expects that the prescribing health professional will also be following General Medical Council guidance, when agreeing to prescribe remotely.
For its part, the home will ensure the following. Care home staff involved in the process should:
- be competent in the communications and procedures involved, including: describing the service user’s conditions and needs (if the person cannot do so on their own), understanding the health professional’s instructions, and communicating them to other staff involved in the person’s care, which could be about general care and treatment, medicines’ administration and monitoring
- ensure that any change to a prescription or prescription of a new medicine by telephone or other remote means is supported in writing (by fax or email) before the next or first dose is given
- ask that the health professional using remote prescribing changes the prescription
- carefully record any prescribing instructions given and check their accuracy with the prescriber
- update the person’s medicines administration record and the care plan as soon as possible, checking accuracy with the written confirmation when available, and highlighting any changes that have been made by the remote prescribing
- record any details of text messages (to be sent and received in exceptional circumstances only) received about a resident’s medicines, and ensure service user confidentiality is kept.

Storage

All medication within the home is safely stored, including blister packs, non-prescription medication, alternative remedies and self-administered medication. A lockable metal drug cabinet and a lockable trolley are provided for this purpose. The keys to the cabinet and trolley are always kept by the senior nurse in charge or by a manager.
Neither the cabinet nor trolley is ever left unlocked or unattended at any time and when not in use, the trolley is secured to a wall.
A lockable fridge is provided for medication that needs to be kept between 2–8°C. The temperature in this fridge is recorded daily at the same time (with recordings taken of actual and minimum/maximum temperatures) and the records are monitored weekly by a designated nurse/manager. The procedure ensures that the fridge temperature is compatible with the temperatures at which the medicines must be stored.
Medicines that require storage between 2–8°C are stored in a separate fridge/separate fridge compartment of a domestic fridge. They are never mixed with normal foodstuff.
The temperatures of the rooms and all storage facilities for medicines are likewise checked and recorded daily with weekly monitoring by a designated nurse/manager to ensure that medicines are always kept within the required range of values, which will be indicated on their labelling and/or patient information leaflet.
All incoming medication is recorded in the stock record, including blister packs. Controlled drugs are recorded in the controlled drugs register. Incoming medication without a clear label stating name of patient, name of medication, expiry date, strength, dose, frequency of administration, start and finish times, must be referred to the community pharmacist.
Stock is checked weekly by the nurse in charge/manager/nominated senior staff member with particular attention paid to expiry dates. Checking enables medicines that are only used periodically to be correctly maintained. Medication is always kept in its original packaging with the service user’s name clearly visible.

Administration and recording

Medication is always administered by a registered first level nurse or by a designated, appropriately trained and competent member of staff.
Staff provide appropriate support to any service user who wishes and is able to take all or some of their own medication.
Medication is only ever administered to a service user 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.
A separate medication record (MAR) chart is kept for each service user using prescribed medication. Staff must carefully check the identity of each service user to ensure that the correct record is being used and that the correct medication is being given to the correct person.
Staff must also check the medication name, the strength of the medication, the dosage instructions and the expiry date. Controlled drugs must always be double-checked by a second suitably trained member of staff. Complex dosage calculations must also be double-checked.
Staff should know the therapeutic use of the medication administered, its normal dose and the side effects, precautions and contra-indications of its use. They should check that the prescription or the label on the medication is clear and unambiguous and that the service user is not allergic to the medication.
Clear and accurate signed records should be kept of all medication administered, withheld or refused.
Both paper-based or electronic medicines administration records must:
- be legible
- be signed by {{org_field_name}} staff or care workers
- be clear and accurate
- have the correct date and time (either the exact time or the time of day the medicine was taken)
- be completed as soon as possible after the person has taken the medicine
- avoid jargon and abbreviations.
All drug errors must be reported to the manager/nurse in charge or to a responsible medical practitioner without delay.
Staff are expected to be always aware of the medication being taken by individual service users and to report any change in condition that might be due to medication or side effects immediately to the nurse in charge/manager. The nurse in charge/manager will then discuss the case with the prescriber, with another prescriber or with the community pharmacist.
Instructions are written into individuals’ care plans about any specific issues to be considered in the giving of their medicines, such as taking medication before, after, or with food, risks of non-compliance, the importance of waking or not waking someone who is sleeping at the time. All such issues will be considered individually by balancing individual wishes and the risks associated with the taking or non-taking of the medication at certain times.
Staff involved in the application of medicines by different routes, including the use of syringes, etc, are always trained and competent in the safe use of these different items of equipment used to assist the taking of medicines.

Disposal

All unwanted or surplus medication, including controlled drugs, is returned to the community pharmacist for disposal and a receipt obtained, or in line with local procedures to a contracted clinical waste disposal service.
When a service user dies, all their medicines are retained for at least seven days before disposal.

Medicines-related safeguarding

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

In {{org_field_name}}, the safety and safeguarding of residents is considered paramount. This includes safety from any misuse of medicines by staff or errors in medicine administration. The home will take all possible action to safeguard residents from such risks, including by explicitly linking its medicines management safeguards with its wider safeguarding processes.
Staff in {{org_field_name}} are required to report and record 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 home will contact an appropriate health professional to check that suitable action has been taken to protect the health and wellbeing of any resident involved — this will usually be the GP.
The home 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 home’s medicines policies and processes, including training for staff.
Residents and/or their family members or carers will be provided with full information about any medicines-related safeguarding incident and about the progress of any investigation.
Residents and/or their family members or carers will be provided with full information on how to report a medicines-related safety incident or any concerns about medication.

Help for service users to take their medication

Where it is identified that a person is potentially starting to experience difficulty managing or taking their own medicine, the first step should be a comprehensive review of their medicines (medicines review). This review should be carried out by a pharmacist or by an appropriate health professional who is part of a multidisciplinary team. The review may lead to a rationalisation or optimisation of their medication.
If the person is still experiencing difficulty with their medicines after the medicines review consideration should be given to providing/recommending aids to support the person to take their medicines. This might include the use of aids such as:
- reminder charts
- winged bottle caps
- large print labels
- alarms (such as notifications on mobile phones)
- tablet splitters
- eye drop aids
- inhaler aids
- audible alarms
- monitored dosage systems (MDS) or multi-compartment compliance aids (MCAs)
- telehealth aids, etc.
The best system for supplying medicines is one that meets the person’s health and care needs and maintains the person’s independence wherever possible.
Monitored dosage systems (MDS) or multi-compartment compliance aids (MCAs) should only be used in line with current best practice guidance, such as that from NICE and the Royal Pharmaceutical Society.
MDS or MCA systems may be of value for some people who have been assessed as having practical problems in managing their medicines. However, NICE guideline (SC1) states that care home providers should determine the best system for supplying medicines for each resident based on the resident’s health and care needs and the aim of maintaining the resident’s independence.
The use of a monitored dosage system should be considered only when an assessment by a health professional (for example, a pharmacist) has been carried out, in line with the Equality Act 2010, and a specific need has been identified to support medicines adherence.
Decisions must take account of the person’s needs and preferences and involve the person and/or their family members or carers and the social care provider in decision-making.
If an MDS or MCA is to be used then care staff should only administer medicines from an aid that has been prepared by a pharmacy or dispensing practice. Care staff must never fill a dosette box or similar compliance aid for a supported person.

Training

In {{org_field_name}}:

all new staff will receive training as part of their induction covering basic information about common medicines and how to recognise and deal with medication problems; those who will be involved in medicines administration will have additional training to the level required by their roles and responsibilities
care staff will be expected to attend refresher training and additional training as required
access to additional training will be supported for those fulfilling any enhanced role
up-to-date records will be kept of all medicines administration training
nursing staff are expected to keep themselves up to date as required in their revalidation process and as specified in their professional code of conduct (The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates, October 2018).

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}}

SCH150. Medication Management in Care Homes