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Medicine Reconciliation and Review in Care Homes Policy

Policy Statement

This policy is written in line with the NICE (2014) guidance on Managing Medicines in Care Homes and other relevant guidance and regulations. It forms part of the home’s approach to assessing needs and risks and for developing, implementing and reviewing service users’ plans of care. It should be used in association with the home’s other policies on medication, particularly its general Medication Management policy.

The policy underlines the home’s commitment to ensuring that each resident’s medication needs are met correctly and safely by showing how it sets up a medication plan (medication reconciliation) and procedures for reviewing a person’s medication.

Listing of Medicines (Medicines Reconciliation)

When a person is referred for admission to the home, we routinely enquire about a person’s needs for medication to make sure that we can accept responsibility for helping the person to take their medication correctly and safely if they become a resident of the home. This means making sure that the home is able to follow all procedures for the correct and safe administration of the person’s medication with the help of staff who are suitably trained and competent to provide the necessary administration and support.

Once it has been agreed that the home can admit the person, the manager or the person responsible for the person’s admission arrangements will ensure that:

• the person’s medication requirements are clearly and accurately stated on their service user plan of care and this information clearly and accurately reflects their needs assessment and any risk factors that have been identified
• the person’s current medication needs can be fully met by the supply of medicines that they bring with them and/or can be sourced by the home following normal prescribing and dispensing procedures.

In any admission to the home, whether the person comes from their own home, as a transfer from hospital, another home or place of residence, the home will ensure that it has the following information to ensure that they receive all their required medication correctly and safely.

• Person’s details, including full name, date of birth, NHS number, address and weight (where appropriate in relation to their medication needs).
• GP’s details (including previous and current, where a change of GP is required).
• Details of other relevant contacts who might affect their medication, as defined by the resident and/or their family, members or carers (for example, their consultant, regular pharmacist, specialist nurse).
• Checks of known allergies and reactions to medicines or ingredients, and the type of reaction experienced.
• A list of medicines the person is currently taking, including name, strength, form, dose, timing and frequency, and what it is taken for.
• Information about recent changes to their medication, including medicines started, stopped or dosage changed, and reason for change.
• Date and time the last dose of any “when required” medicine was taken, or of any medicine given less often than once a day (weekly or monthly medicines).
• Other information, including when the medicine should be reviewed or monitored, and any support the resident needs to carry on taking the medicine.
• Checks on what information has been given to the resident and/or family members or carers about their medication.
• Details of the person completing the medicines reconciliation (name, job title) and the date are recorded.

Medication Reviews

A medication check should be included in the regular reviewing of a person’s plan of care. If not, the home manager or key worker will link up with each person’s GP to ensure that an individual’s medication needs are being regularly reviewed.

Medication reviews will usually involve the resident and/or their family members, the relevant care staff and health care practitioners, such as GP, pharmacist, specialist nurse, and consultants where involved.

Such reviews should be built around the needs of each individual and their use of medication. They can take different forms and a multi-disciplinary medication review might be needed in some instances.

A medication review process involves:

• being clear about the purpose of the review
• obtaining the views of the resident (and/or their family members or carers, as appropriate and in line with the resident’s wishes) about their medicines
• discussing any problems that they are experiencing with their medication, such as side effects, reactions, or issues with the mode of administration
• checking on the effectiveness of all prescribed, over-the-counter and complementary medicines that the resident is taking or using, and what these are for and any associated risks
• checking on how safe the medicines are, how well they work, how appropriate they are and whether their use is in line with national guidance
• deciding if any monitoring tests are needed
• checking if there are any deviations that might have been made to the taking of the prescribed medication, such as through refusal or non-compliance
• identifying if further information or support is needed by the resident (and/or their family members or carers).

Records are kept of each review and all decisions will feature on the person’s plan of care.

Note:

The home follows all required mental capacity/incapacity processes for involving people who might lack mental capacity to consent to their medication reconciliation and review procedures.

Training

All staff who are involved in medication reconciliation and reviewing procedures receive the required training and supervision to enable them to carry out their duties competently.

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