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SL174-Medication management-PC

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Medication Management Policy

1. Purpose and Scope

This policy outlines the procedures and standards for safe medication management at {{org_field_name}}. It applies to all staff and adults (18+ including older adults 65+) with physical disabilities receiving support with personal care in our supported living services. The policy covers all aspects of medicines handling – from ordering to disposal – to ensure compliance with regulatory requirements and best practices. Our organisation is registered with CQC for the regulated activity of Personal Care which includes ancillary support with medication administration.

Scope: This policy is to be followed by all employees (care staff, support workers, managers) involved in prompting, assisting, or administering medications. It encompasses prescribed medicines, over-the-counter remedies, PRN (as-needed) medications, and Controlled Drugs (CDs). The service user group covered is adults with physical disabilities; we do not provide services for individuals with primary mental health needs, autism, or significant cognitive impairments. Consequently, covert medication (giving medicines without a person’s knowledge) is not practiced under this policy, as service users are presumed to have capacity to make their own decisions about medicines. Any exceptions (e.g. a rare temporary loss of capacity) would be managed under the Mental Capacity Act 2005, but covert administration is generally outside our service scope.

The overall aim is to support people to manage their own medicines as much as possible while ensuring safety and compliance with all legal and Care Quality Commission (CQC) requirements. This policy should be read in conjunction with each individual’s care plan and medication risk assessment. It will be reviewed regularly to keep it up-to-date with current laws and guidance (see Policy Review and Governance).

2. Legal and Regulatory Framework

Medication management at {{org_field_name}} is carried out in line with all relevant legislation, regulations, and guidance to ensure safe, person-centred care. Key frameworks include:

All staff must familiarize themselves with this policy and relevant regulations. If any aspect of this policy conflicts with updated law or guidance, the legal requirement takes precedence and the policy will be updated accordingly. By following this framework, {{org_field_name}} ensures medication support is safe, lawful, and focused on the individuals’ needs and rights.

3. Roles and Responsibilities

Safe medication management is a shared responsibility within the organisation. Clear roles and accountability help ensure consistent practice:

In summary, everyone involved has a part to play: the organisation’s management provides the system and training, staff execute day-to-day support safely, and service users are encouraged to be as actively involved as possible. By understanding our respective responsibilities, we ensure a robust chain of accountability for medication safety.

4. Levels of Support (Prompting, Assisting, Administering)

We tailor the level of medication support to each individual’s needs and preferences, promoting independence wherever possible. The agreed level of support is documented in the care plan following assessment. Generally, three levels of medicines support are recognised:

Important: Only those staff trained and deemed competent are allowed to assist with or administer medications (levels 2 and 3). Prompting (level 1) still requires that staff have basic medication awareness training, since even prompting can have safety implications (they must know what to do if the person says they already took it, etc.). The care plan will clearly state what level of support is required for each medicine (some individuals might self-manage certain meds and need help with others). Staff should never exceed the agreed level of support – for example, do not physically administer a medicine if the care plan says only prompting is needed. If a change in support level seems necessary (e.g. the person is struggling more with self-medicating), inform the manager so the care plan can be updated after reassessment.

We encourage and support individuals to move towards self-administration wherever safe and feasible, as this promotes independence and control. Even when staff administer medicines, the person is kept at the centre of the process (choosing how they prefer to take it, being informed about their medicines, etc.). All levels of support are carried out with the person’s consent and understanding.

5. Consent and Capacity

Consent: We ensure that the service user’s consent is obtained for all medication support. In practice, consent is initially obtained during care planning – the individual agrees to the medication support as part of their service. However, consent is an ongoing process: staff must seek consent each time they assist with or administer a medicine. This can be as simple as offering the medicine and confirming the person is willing to take it at that moment. If someone declines or resists, that is considered a refusal (see Refused or Missed Doses section) and must be respected, provided they have capacity to make that decision. A person with capacity has the right to refuse medication, even if others consider it not in their best interest. Staff will not force or trick anyone into taking medication. They will explain any potential consequences of refusal calmly and report the refusal, but the individual’s choice is paramount.

Presumption of Capacity: The Mental Capacity Act 2005 principles underpin our approach – we presume every adult we support has the mental capacity to make decisions about their medication unless there is evidence to the contrary. Our user group (adults with physical disabilities) generally can understand and decide on their medicines. We avoid making assumptions based on disability; needing help physically does not mean inability to decide. We provide information in an accessible way to support informed decisions (for example, using non-medical language, large-print labels, or the Patient Information Leaflet). If a person has communication needs, we use appropriate methods or tools so they can consent or express their wishes about medicines.

Fluctuating or Lacking Capacity: If there are signs a person may lack capacity to comprehend a specific medication decision (for example, due to a sudden health crisis, acute confusion, etc.), staff must involve the Registered Manager and possibly a healthcare professional. A capacity assessment should be conducted for the particular decision (e.g. “Does the person understand the need to take their antibiotic now?”). If it’s determined the person truly lacks capacity for that decision, any action must be in their best interests following the Mental Capacity Act guidelines – typically this involves consulting with their GP and any family or representatives. Covert administration (hiding medicine in food or drink) is not allowed in our service unless a formal best interest decision is made with medical oversight and documented – given our service criteria, this scenario is highly unlikely. We emphasize that covert medication cannot be done unilaterally by care staff and is omitted from routine practice here. Instead, if someone with cognitive impairment refuses medicine, we seek medical advice rather than concealing doses.

Right to Refuse: When a person with capacity refuses a medication, staff will:

In all cases, we treat the service user as the decision-maker about taking medication, unless a formal best-interest process has determined otherwise. By keeping consent and capacity central, we uphold individuals’ rights while still acting in their best health interests.

6. Medication Ordering and Receiving

Ensuring a continuous, timely supply of the right medications is a critical part of safe support. The process for ordering and receiving medicines in our service is as follows:

By maintaining a reliable ordering and receiving system, we aim to never run out of a required medication. Regulation 12 of the HSCA Regulations 2014 explicitly requires that providers ensure the proper and safe supply of medicines. In practice, this means staff must be proactive and organized about ordering. If any difficulties arise (like prescription delays), the manager will be alerted so contingency plans (e.g. interim GP order, contacting out-of-hours GP) can be made.

7. Medication Storage

Proper storage of medicines is vital to maintain their effectiveness and prevent accidents. Our policy for storage in supported living settings is:

If risks are identified, we implement safer storage measures. Lockable Medicine Box: We can provide a small lockable box or cupboard. The key may be kept by the person or by staff, depending on capacity and preference (if the person has capacity and wants control, they keep the key; if they prefer staff manage it, staff hold the key, documented on care plan). We identify which staff are authorized to access the medicines (usually those trained in medication support). If no significant risk is present, medications can be stored in a normal cupboard or drawer of the person’s choosing – but separated from household items, and ideally not in damp or hot areas like near sinks or radiators.

By adhering to these storage protocols, we ensure medications remain effective (not degraded by improper storage) and are safe from misuses or accidents. We document in each person’s file how and where their medicines are stored and any specific instructions (e.g. “Store inhaler in bedside drawer, no lock needed, client prefers quick access” or “All medicines in locked metal box in kitchen cupboard – key with morning carer”). We review storage arrangements if the person’s situation changes (for instance, if they start to struggle with remembering doses, we might introduce more controlled storage).

8. Administration Procedures

When administering medication (or assisting with administration), staff must follow a step-by-step procedure to ensure safety and accuracy every time. The process is grounded in the “6 Rs” (sometimes called 6 Rights) of safe medication administration:

  1. Right Person – Confirm the identity of the service user. In supported living, staff usually know the individual they are supporting, but it remains good practice to double-check, especially if supporting multiple people in one location. For example, confirm by calling the person by name or checking their photo ID in the care plan if available. This prevents any mix-up if two tenants have medication rounds around the same time.
  2. Right Medicine – Verify that the medication you are about to give is the correct one for this person at this time. Compare the pharmacy label and name of the drug with the MAR chart entry:
    • Check the name of the medicine, formulation (e.g. tablet, cream, inhaler) and strength against what is listed on the MAR chart.
    • Ensure the medication is in-date (not expired). For liquids, eye drops, creams etc., check if an “opened on” date is noted and that it’s within the usable period. If a medicine is expired or the label is illegible or detached, do not administer and seek a replacement/clarification.
  3. Right Dose – Check the dose on the MAR chart and pharmacy label:
    • If the dose is a certain number of tablets or a volume of liquid, measure it carefully. Use appropriate measuring devices (e.g. oral syringe for small liquid doses, medication spoons or graduated cups). Do not estimate doses by eye.
    • If tablets need halving (and are scored for splitting), use a tablet cutter if provided. Staff should not alter form (crush/open capsules) unless explicitly instructed by the prescriber/pharmacist, because this can affect how the medicine works.
    • For variable doses (e.g. “1–2 tablets as needed”), follow the PRN protocol or the person’s direction (see PRN section) and record the actual amount given.
  4. Right Time – Confirm it is the correct time for the medication:
    • MAR charts will indicate when doses are due (e.g. morning, lunchtime, evening, bedtime or specific clock times).
    • There is often an accepted window (e.g. 1 hour before/after the due time) for non-critical medicines, but for time-sensitive medicines (like Parkinson’s medications, insulin, etc.), these must be given as close to the exact time as possible. If our scheduling of visits is an issue, management will ensure visit times accommodate important medicines.
    • Check the last administration time if PRN or doses given by others, to avoid giving a dose too early.
    • Some medicines relate to food intake (e.g. “before food” or “after food”) – ensure the timing with meals is correct as per instructions.
  5. Right Route – Make sure you administer via the correct route as prescribed (oral, topical, inhaled, eye/ear drops, etc.).
    • For tablets/capsules: ensure the person has water or fluid to swallow unless told to take dry or chew.
    • For creams/ointments: wear gloves, apply to the correct site as directed, in the correct manner (rub in gently, etc.), and note where applied on any body map if used.
    • Inhalers: assist to shake if required, and ensure the person uses proper technique; staff may need training for certain devices. If using a spacer, help assemble it.
    • Eye or ear drops: check which eye/ear and how many drops. Maintain cleanliness (do not touch dropper tip to any surface).
    • Transdermal patches: apply to the correct area, date/time of application should be written on patch or recorded, and rotate sites per instructions.
  6. Right Record – Document the administration immediately after the person has taken the medicine (never beforehand). Sign or initial the MAR chart for that dose. If the dose was not given, circle the relevant space and use the appropriate code (e.g. “R” for refused, “O” for omitted with explanation). For PRN, record the exact dose given and reason if required (example: “8pm – 5ml given for cough, [initials]”). Good record-keeping is part of safe care (Regulation 17).

Step-by-Step Procedure:

  1. Preparation: Wash your hands or use hand sanitizer before handling medicines. Gather the MAR chart, pen, any measuring devices needed, and access the stored medications (unlock cupboard if needed). Ensure you have a well-lit area to read labels, and a clean surface to work on.
  2. Verify and Check: Read the MAR chart for the scheduled time and identify which medicines are due. For each medicine due:
    • Locate the medication container.
    • Check label against MAR for person’s name, drug name, dose, route, and time.
    • Check any special instructions (e.g. “take with food”, “avoid dairy”, “wear gloves to apply”).
    • Check the medicine appearance if familiar – if something looks different (different pill shape or colour than previous), pause and verify it’s correct (could be a generic substitution).
  3. Communicate with the Person: Explain to the service user which medication(s) you are about to assist with. For example: “It’s time for your blood pressure tablet and pain relief. Is that okay now?” Obtain their consent or ascertain willingness. This gives them an opportunity to ask questions or mention if they already took something.
  4. Administration:
    • Remove the correct dose from the container at the time of administration (do not prepare doses far in advance). Only remove one person’s medications at a time to avoid mix-ups.
    • If a tablet or capsule, pop it out of the blister or pour from bottle into the lid then a medicine cup – avoid directly touching medicine with fingers if possible.
    • Hand the medication to the person or assist them in taking it according to their ability (they might self-put in mouth, or you may place it in their hand, or in some cases gently to their lips if they cannot use their hands and give permission).
    • Offer water or appropriate fluid and ensure the person is sitting upright (especially for oral meds).
    • Observe that the medication is taken/swallowed. We do not force the person to open their mouth, but we encourage them to drink and finish the dose. If the person chooses not to take it at the last moment, respect that and treat as a refusal.
    • For non-oral meds, administer as trained: e.g. apply cream with gloves, ensure patches adhere properly, count inhaler puffs if assisting, etc.
  5. Post-Administration: Confirm with the person that they are okay (no immediate discomfort). Tidy up – dispose of any waste (e.g. used sachets, gloves, medicine cups – following sharps protocol if any needles used by healthcare professionals, etc.). Lock away medicines if needed before moving on.
  6. Record Immediately: Document on the MAR chart for each medicine:
    • Initial in the box for that dose/time if given successfully.
    • If the person refused or it was not given, mark the code and write a note (“Refused – will try later” or “Not in stock” or other reason) as applicable. Also inform the manager if a dose is missed for any reason.
    • If a PRN dose, note the time and amount given in the MAR as well.
    • If the medication is a Controlled Drug, you will also update the running stock count if we maintain one, and both staff sign the controlled drug administration record (if two are present, though only one is legally required).
  7. Monitoring Afterward: Remain alert for any immediate adverse effects. If the person reports feeling unwell or shows a reaction (e.g. rash, vomiting, dizziness) after a medication, take appropriate action – this may involve contacting a GP or NHS 111 for advice, or emergency services if severe (see Medication Errors/Incidents if it might be an adverse drug reaction).

If there’s any doubt or discrepancy at any stage, do not administer and consult the manager or pharmacist. For example, if the MAR chart says 2 tablets but the pharmacy label says 1, pause and clarify – the prescription might have changed. Or if the person says “I already took that this morning,” verify against the MAR to ensure they didn’t and perhaps they are mistaken, but if there’s uncertainty, do not give a potentially duplicate dose. Communication is key: when in doubt, phone the GP or pharmacy before proceeding.

Special circumstances:

By following this thorough procedure every time, we greatly reduce the risk of medication errors. Staff are trained to treat each administration with attention to detail, even if routine, as complacency can lead to mistakes. The manager conducts periodic observations and competency checks to ensure procedures are followed consistently.

9. Refused or Missed Doses

It is the individual’s right to decline medication, and there are times when doses might be missed inadvertently. Our approach is to handle these situations safely and transparently:

Refusal of Medication: If a service user refuses a medication (at the time offered or indicates they don’t want to take it):

We fully acknowledge the individual’s autonomy, while also making sure they (and their healthcare team) are aware of any potential health consequences of missed doses.

Missed Doses (Errors or Other Reasons):

Follow-Up to Missed/Refused Doses:
All missed or refused doses are reviewed by the manager. Patterns are analysed – if a certain med is often missed or refused, we investigate why. It might lead to changes like rescheduling administration to a different time of day when the person is more receptive, or getting a long-acting formulation to reduce dosing frequency, etc. In essence, every missed dose is a signal to improve either our system or the care plan if possible.

The care plan is updated if any new instructions arise (for instance, GP says if a dose is missed, do X). We aim to minimize missed doses through good scheduling and person-centred approaches, but when they occur, prompt action ensures the person’s well-being is maintained.

Lastly, our documentation and open communication about refusals/misses demonstrates to regulators that we handle these in line with the Duty of Candour and safe practice (not hiding errors). People have the right to make choices about their medicines, and our role is to support them safely even when those choices are to decline a treatment.

10. PRN Protocols (As-Needed Medication)

PRN (from the Latin “pro re nata”) medications are those taken only “as needed” for specific symptoms or situations, rather than on a fixed schedule. Examples include painkillers taken only when pain arises, anxiety medication used during acute episodes, or inhalers for occasional asthma symptoms. Because PRN medicines are not given routinely, clear protocols are essential so that staff know when and how to administer them appropriately and consistently.

For each PRN medicine that a person has, {{org_field_name}} will ensure there is a written PRN protocol in the care plan or kept with the MAR chart. This protocol provides detailed guidance, including:

Staff are trained to consult this PRN protocol whenever considering giving an as-needed medicine. They should also double-check the prescription label for any additional directions each time.

Offering PRN Medication:

Recording PRN Use:
Every time a PRN is administered, staff must document it on the MAR chart just like a regular medication but also note it was given PRN. This includes:

Monitoring and Review of PRN Use:
We keep an eye on how often PRNs are used:

Special cases:

Our PRN protocols ensure that even though these medications are not scheduled, their use is not arbitrary – it’s carefully defined and person-specific. Staff find these protocols helpful to deliver consistent support, and people receiving care can trust that they will get their PRN medication when they truly need it, and not get it inappropriately when they don’t.

11. Controlled Drugs (CDs)

Controlled Drugs (CDs) are medicines that are subject to special legal controls under the Misuse of Drugs legislation due to their potential for abuse or harm. They include certain strong painkillers (like morphine, fentanyl), sedatives, and other medications which could be misused. We handle controlled drugs with particular care to ensure security and safety, while still enabling the person to receive their medication when needed.

Key procedures for Controlled Drugs in our service:

By following these measures, we maintain a high level of vigilance around controlled drugs, reflecting both their benefits for the person (often essential for quality of life in pain management) and the potential risks. Our policy aligns with CQC guidance that the ordering, storing, administering, recording, and disposal of controlled drugs must be covered in our procedures. We aim to ensure that service users get the pain relief or therapy they need from CDs without undue restriction, but with safeguards that protect everyone.

12. Self-Medication and Risk Assessment

Promoting independence in medication management is a core value for our service. Many people with physical disabilities are fully able to direct and control their own medicines with minimal support. We encourage self-medication whenever safely possible, meaning the individual keeps and takes their medication by themselves (with the service’s role being limited to perhaps stocking and monitoring or simply being aware).

Initial Assessment: Upon starting service, each person’s ability and desire to manage their own medication is assessed as part of the care planning process. Factors considered include:

This assessment is documented, and a decision is made collaboratively. If the person is capable and wishes to self-medicate, we will respect that and provide the support level they ask for (which might be just “prompt me, but I’ll do it” or “I’ll do everything, just you record it”).

Risk Assessment and Plan: If self-medication is the goal, a risk assessment is completed detailing any measures needed to facilitate it safely. For example:

The care plan will clearly state “Service user to self-administer [all/specific] medications with [what support] and [frequency of review].”

Levels of Self-Medication:

Review and Monitoring: Self-medication capabilities can change. We review the arrangement regularly (for example, every 3 months or at each review meeting) and whenever there is a change in health:

Documentation: The care plan’s risk assessment will note that the person self-medicates and outline what staff will and won’t do. For example, “Mr. X keeps all medication in his possession and self-administers. Staff to remind at 9pm for blood thinner; Mr. X confirms when taken. Staff do weekly check of blister pack remaining count to ensure adherence. No MAR entries for self-administered morning meds, only record prompts given for evening dose.”

We ensure that all staff are aware (through handovers and the care plan) of who is self-medicating, so no one mistakenly tries to take over. We also make sure the GP and pharmacy know – if someone entirely self-manages, the pharmacy might give them advice directly or package differently as per their preference (some independent clients might not want bottles relabeled “take at 8am” because they know their routine, etc.).

Benefits: Allowing self-medication supports dignity and autonomy. For adults with physical disabilities, retaining control of one’s medication schedule can be empowering, and we support that by providing tools or minimal assistance as needed rather than automatically doing it for them.

Safety Net: If at any time a self-medicating person makes a medication error or there is an incident (e.g. they took an extra dose by mistake or forgot multiple doses), staff will respond supportively, address any immediate health needs (e.g. get medical advice), and then review the risk assessment. It might mean adjusting the plan to provide a bit more support until they are back on track. We promote a no-blame culture even for self-admin – mistakes can happen, and we treat it as something to learn from and adjust.

In summary, self-medication is the default wherever feasible. We want our service users to feel in control. Our role is to make sure it’s done safely through initial assessment, periodic review, and offering adaptive support (like devices or reminders) rather than taking over unnecessarily. Everything is documented clearly so that all parties know the agreed approach.

13. Record Keeping (MAR Charts and Stock Records)

Accurate record keeping is a legal requirement and an essential part of safe medication management. We maintain thorough records for all medications we handle, in line with Regulation 17 (Good Governance) which mandates up-to-date and accurate medicine records. Our record-keeping practices include:

Each new cycle (usually monthly) a new MAR is started, reflecting any medication changes. We prefer pharmacy-printed MAR charts to reduce transcription errors. If staff ever have to transcribe a MAR (e.g. emergency prescription at hospital discharge), two staff should check the entry and sign it off.

Along with the code, staff writes a brief note in the MAR’s comments section or communication book if needed (e.g. “R – refused, said feeling nauseous” or “O – not given, pharmacy didn’t supply – reported to manager”).

All these become part of the person’s medication records and are kept together for reference and audit.

In summary, if it’s related to medication – we document it. Proper records protect the service user (by ensuring consistency and continuity of care) and the staff (by providing evidence of actions taken). We also have a process for medication reconciliation when a person returns from hospital or respite – comparing the hospital discharge meds with our records and updating MAR accordingly, to ensure our records match what the person should now be taking.

By diligently keeping MARs and other records up to date, we can quickly answer the “who, what, when, how” of any medication query, thereby preventing errors and demonstrating compliance.

14. Medication Reviews

Regular medication reviews are essential to ensure that each person’s medicines are still appropriate, effective, and as minimal as necessary. Medication reviews are usually led by healthcare professionals (such as the person’s GP or a pharmacist), but our staff play a role in facilitating and contributing to these reviews.

Frequency of Reviews: We advocate that each service user has at least an annual medication review with their GP or prescriber, in line with NHS guidance (older adults and those on multiple medications often get yearly reviews). Some individuals may require more frequent reviews – for example, if they are on complex regimens, or psychotropic medications, or if there have been significant health changes. The Care Act emphasizes the importance of reviews as part of ongoing care planning. We diarize known GP review schedules and prompt the person or GP if a review is due.

Involvement of Service User: The person receiving the medication is at the center of the review. We encourage them to express how they feel about their medicines – what’s working, what’s not, any side effects or difficulties. Their views, wishes, and aspirations regarding treatment should be included. If needed, we help them articulate these or even write down questions ahead of a GP appointment.

Role of Staff in Reviews: Our staff can provide valuable input to medication reviews because we observe the day-to-day effects of the medicines. With the service user’s consent, we may:

Medication Changes: After any medication review or doctor’s visit where meds are changed:

Polypharmacy and Simplification: Many of our service users, especially older adults, might be on multiple medications. Part of review is to assess if some medications can be deprescribed (stopped) or simplified. We support the concept of only using medication that is beneficial. For instance, if during a review the person and GP find that a particular tablet might no longer be needed (perhaps originally for short-term use and just got continued), that might be removed to lighten the pill burden. We encourage questions like “Is this still needed?” or “Could a once-daily alternative be used instead of this twice-daily med?” as appropriate.

Interdisciplinary Approach: Sometimes a pharmacist (for example, a clinical pharmacist in the GP practice or a community pharmacist) might do a medication use review or advise on optimization. We collaborate with them, providing MAR charts or lists of what the person actually takes (including any over-the-counter supplements the person uses) to give a full picture. This ensures the review accounts for everything and checks for drug interactions or duplications.

Outcomes of Reviews: Typical results might be:

We document any decisions or changes from the review in the care plan and update the MAR. If the review concluded “continue all medications, no changes”, we note the date of review and that it occurred.

Person-Centred Focus: It’s not just a tick-box. We really emphasize the person’s understanding – after a review, staff will ask the person if they are clear on any new instructions. If not, we’ll explain again or contact the GP for clarification. Also, as per Accessible Information Standard, if someone needs the review information in a certain format (easy-read summary, etc.), we help facilitate that.

Ongoing Monitoring: Between formal reviews, if staff notice any medication-related problems, we don’t wait. For example, if the person is newly drowsy after a med was increased, we might arrange a GP phone call to review that single issue rather than waiting months. In essence, medication management is an ongoing process of review in practice, with the formal review as a checkpoint.

By ensuring medication reviews happen and acting on them, we help maintain effective therapy and minimize unnecessary medications. This improves outcomes for service users (less pill burden, fewer side effects, better understanding of their regimen) and aligns with CQC’s focus on effective care. The organisation keeps evidence of reviews (dates, summary of any changes) as part of care records.

15. Training and Competency

All staff involved in any aspect of medication support must be properly trained and assessed as competent before they take on those duties unsupervised. Medication errors can have serious consequences, so we ensure a high level of staff preparedness in line with NICE guidelines and CQC expectations.

Our approach to training and competency includes:

We ensure trainers are qualified (e.g. a pharmacist, nurse, or a certified medication trainer).

Only if the staff member is deemed competent (meeting all criteria) will they be authorized by the manager to administer medicines unsupervised. If not, further training and supervised practice are given.

Through robust training and competency assessments, we aim to ensure all staff are confident and skilled in supporting people with medicines. This not only prevents errors but also means staff can educate and reassure service users (e.g. explaining what a medicine is for if the person asks). Competent staff = safe service; therefore, we invest in this continuously. If any doubt exists about a staff’s competence, they are removed from medication duties until retraining and re-assessment is successfully completed.

16. Audits and Monitoring

To maintain high standards, {{org_field_name}} conducts regular audits and monitoring of its medication management practices. Continuous oversight allows us to catch potential issues early, learn from mistakes, and demonstrate compliance with the governance expectations (Regulation 17).

Our approach includes:

Findings are recorded. If minor documentation issues are found, the auditor will feed back to the staff team or individuals for improvement. Significant issues (like a dose not signed with no explanation) prompt an immediate investigation (was it given and just not signed? Or actually missed?).

We use an audit checklist possibly (Appendix form) to ensure consistency in what we check.

Such audits help ensure that returns to pharmacy are being done and that ordering is in sync with actual use.

A summary of medication incidents is prepared, say quarterly, to look for patterns. We then implement actions: e.g. if audits show frequent late ordering of meds, we might introduce a new reorder tracking form; if incidents show staff confusion with a MAR format, we talk to the pharmacy about improvements or retrain staff on reading it.

We share lessons with the whole care team in supervisions or team meetings, fostering a culture of continuous improvement. CQC encourages providers to learn from audits and share learning from medicines errors to reduce future likelihood.

In summary, through systematic auditing and monitoring, we aim to catch issues proactively rather than reactively. This continuous oversight ensures that our medication management remains effective, safe, and compliant, and that we can demonstrate to regulators our commitment to high-quality care.

17. Medication Errors and Incident Handling

Despite best efforts, medication errors or incidents can occur. An error might include giving the wrong medication or dose, giving it to the wrong person, missing a dose, giving it at the wrong time (significantly), or administering in a wrong way. Non-adherence by the person (like refusal) is not an “error” by staff, but a medication-related incident. Our policy is to treat all medication errors and near-misses seriously, with immediate action to ensure the person’s safety and a full review to prevent recurrence. We foster a “fair blame” culture, meaning staff are encouraged to report mistakes without fear, so we can learn rather than hide errors.

Immediate Actions When an Error is Discovered:

  1. Ensure Safety of the Service User: The first priority is the health of the person who may have been affected. Depending on the nature of the error:
    • If a dose was missed or given late: Assess if this could have a harmful effect. For example, missing a dose of an anticonvulsant – risk of seizure; giving a blood pressure pill late – usually not immediately harmful but needs adjustment.
    • If the wrong medication or an overdose was given: Quickly determine what was taken and how much.
    • Seek Medical Advice/Help: Call the GP or NHS 111 for guidance on what to do, unless the person’s condition suggests a 999 emergency (e.g. difficulty breathing, collapse – then call emergency services immediately). If poison control advice is needed, the 111 service can provide that. Have information ready: what medication, what dose, time, and the person’s details.
    • Follow any instructions (monitor vital signs, give food or water, go to A&E, etc.). If advised by a health professional, do not hesitate to call an ambulance.
    • Keep the person comfortable and under closer observation. Explain to them calmly what happened (unless medically contraindicated to upset them immediately) and that we are taking care of it.
    • If the person appears well and the advice is to observe, do so and avoid leaving them alone until reasonable time has passed or until a healthcare professional says it’s okay.
  2. Inform the Person and Apologize: As per Duty of Candour (Regulation 20), if the error has resulted in any potential or actual harm, we must inform the person (and/or their representative/family if appropriate) transparently. Even if no immediate harm is evident, we typically let the person know of a significant mistake (“I’m sorry, I realize I gave you the wrong tablet this morning. We have contacted your doctor and are monitoring you.”). We offer a sincere apology for the error and the distress it may cause. For minor errors (like realizing 10 minutes late that we gave a pill at 9:00 instead of 8:00), use judgment, but generally honesty is best practice.
  3. Notify Management: Staff must report the incident to the Registered Manager (or on-call supervisor) as soon as the immediate health concerns are addressed. Even if they believe no harm occurred, they should still report it. If the manager is unavailable, escalate to the senior person on duty or follow on-call procedures. Early reporting allows managerial support for the steps above and for beginning incident documentation.
  4. Secure the Scene/Evidence: Preserve any evidence that may help understand what happened:
    • Save any packaging or medication remnants (e.g. if the wrong pills were given, keep those blister packs separate).
    • Do not alter the MAR or try to “fix” entries retroactively in a deceptive way. Instead, mark what actually happened.
    • If it was a dispensing or pharmacy error (e.g. label error), isolate that medication supply.

Follow-Up and Investigation:

We will err on the side of caution – if unsure, the manager will consult CQC guidance or call them. There’s no penalty for over-reporting, but failure to notify when required is serious.

In essence, our incident handling protocol aims to be swift, transparent, and improvement-oriented. We cannot change the mistake that happened, but we can ensure the person is cared for and do everything in our power to prevent it from happening again. Over time, tracking and learning from errors (and near errors) leads to a safer service.

18. Medication Disposal

Proper disposal of medications is important to prevent environmental contamination, misuse, or accidental ingestion. Our policy ensures that any medicines that are no longer needed by the service user are disposed of safely and legally.

Scenarios where disposal is needed include: discontinued medications, expired stock, surplus medication (e.g. dose changed so old strength not used), medications of a person who has passed away, or sharps like insulin pens if applicable.

Our procedures for medication disposal:

These items are clearly marked (or separated) as “to be disposed – not for use”.

These records are important to prove we’ve not just lost medication and to be accountable especially for controlled drugs.

Special Cases:

By strictly controlling how medicines are disposed, we prevent any potential harm that could come from someone taking medicine that’s not theirs or that’s expired. It also helps keep the environment safe from pharmaceutical contamination. All staff are briefed on identifying medications for disposal and the importance of not just tossing them out.

Finally, disposal actions are often communicated to the GP as needed – e.g. if we returned a lot of tablets because a person wasn’t taking them, we might inform the GP of non-adherence issues. But usually disposal is straightforward and routine.

19. Confidentiality and Information Handling

Medication information is part of an individual’s private health data, and we treat it with the same level of confidentiality as any other personal information. Staff must handle all medication records and details in accordance with data protection laws (GDPR/Data Protection Act 2018) and our confidentiality policies.

Key points regarding confidentiality and meds:

By upholding confidentiality, we maintain trust with our service users. They need to feel confident that their medical details are handled with respect and not shared inappropriately. This is also legally mandated by GDPR and expected by CQC as part of treating people with dignity and respect.

In summary, medication information is on a need-to-know basis: shared with those who need it for the person’s care (and with consent when required), and protected from others. We keep records secure and private at all times.

20. Policy Review and Governance

This Medication Management Policy will be kept up-to-date and reviewed regularly to ensure it remains in full compliance with current laws, regulations, and best practices. We recognize that guidance can change (for example, NICE might update recommendations, or CQC might issue new standards), so we are committed to keeping our policy and practices current.

Key points regarding review and governance of this policy:

The governance team ensures these documents align and cross-reference appropriately. For example, our Statement of Purpose filed with CQC should reflect that we handle medication support as part of personal care – this policy supports that statement by outlining how.

In closing, this Medication Management Policy reflects our organisation’s commitment to safe, person-centred medication practices in supported living. It will continue to evolve with input from frontline staff, regulatory bodies, and the individuals we support. Regular review and strong governance oversight ensure that the policy is not just paperwork, but a living framework that genuinely guides daily practice and upholds the high standards expected by CQC and the law.

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