This is one of the most complex areas within the domiciliary and supported living care sector. Prime Recruitment is aware of the need for clear and practical guidance for staff involved in this area of work.
Most service users who require supported living services are prescribed some form of medication at some time as part of their treatment by their doctor or nurse.
Some service users are able to be responsible for their own medication, but some require help from the organization’s staff. Prime Recruitment believes that any aid offered by our staff to assist a service user to take their medication, or to administer medication, must be agreed with the service user and Care Manager and recorded in the care plan according to the organization’s Medication Policy.
Prime Recruitment understands that taking medication is essential for the health and well-being of the service user but the organization also understands that there are circumstances where in some service users may fail to comply with their prescribed treatments; where in self-medicating service users may fail to take their medication as directed; or non-self-medicating service users may refuse prescribed medication, or fail to swallow it and then dispose of it. In such cases the organization is clear that its staff have no right to force non-compliant service users to take their medication but they do have a duty to report cases of non-compliance back to their line manager who will inform the service user's GP and/or other prescriber.
1.1 Legislative Framework
Medicine Act 1968 (and Amendments)
Misuse of Drugs Act 1971
Misuse of Drugs (Safe Custody) Regulations 1973
Access to Health Records 1990
Control of Substances Hazardous to Health (COSHH) Regulations 1999
Data Protection Act 2018
Hazardous Waste Regulations 2005
Health and Social Care Act 2008 (Regulation 2014)
Managing medicines for adults receiving social care in the community NICE Guideline (NC 67)
This list is not exhaustive, but highlights the complexity of this area.
All medication training will be delivered by a qualified and trained member of staff. All staff will complete this course during induction of commencement of duties, or before if required. It is the intention of this organization to build up good community-based relationships with local pharmacies, whose advice and guidance is invaluable and appreciated.
The staff line manager is responsible in ensuring that the staff are assessed to be competent in the management of service users' medication. The competency assessments are part of the staff's supervised practice and ought to be carried out at least six-monthly, or more frequently, when necessary.
1.2 Prescribing Medication
"Prescribers" are NHS professional who can write (prescribe) NHS prescriptions.
The process by which medicines are prescribed is determined by statute.
GP, Dentists, Physiotherapists, Chiropodists and radiographers are all "Prescribers" in law, and are recognized as an appropriate service user. The following are excluded from the NHS list:
Any complimentary Health Practitioner, Medical Herbalist, Chiropractor, Osteopathic, Practitioner & Health Shop Assistant.
All references to observations requested means any observations requested and recorded in the Care Plan (these requests must come via a Health Professional, e.g. District nurse, GP).
1.3 Assessment of medication needs
Service users who are supported in their own homes by this organization may be responsible, for their own medicines- both prescribed and non-prescribed. Some are able to fully administer their own medicines, others may require a little support to enable them to continue being self-administering. This is identified through a risk assessment. (This is called general support.)
With consent staff may administer prescribed medication (including controlled drugs) to a service user, so long as this is in accordance with the prescriber's directions (Medicines Act 1968). (This is called 'Administering Medication').
Where medication e.g. PEG feeding is given by 'specialized techniques,' staff will need additional specialized training. No staff will participate in any specialized technique unless they have the express permission of the managing director ;the process is entered in the care plan; the appropriate level of specialist training has been undertaken and the level of competency assessed by an appropriate Health professional. This training must be carried out for each service user.
Staff must not offer advice to a service user regarding 'over the counter' medicines or complementary treatments.
1.4 Expired Medication
Medicines have expiry dates to inform when to use them by. After the expiry date medicines
•not be safe
•not be as effective
The expiry date is found on the medicine packaging or on the label.
It may say: "Expiry, expiry date, expires, exp., exp date, use by and use before"
The Expiry dates are applied to medicine by the manufacturer that produces it or the pharmacist who supplies it.
Medication must not be administered after the end of the month given: For example, if the expiry date is June 2019 the medicine must not be administered after June 31st, 2019.
Expiry dates are checked:
• each time the medication is administered by the staff member
• when the medication stock is checked every 28 days before being reordered and documented on the medication records
• when the medication arrives from the pharmacy
Medicine with a limited life span once opened, must have expiry date written on the container by the member of staff who opens it. The guidance information is found on the pharmacy label e.g. Do not use after 28 days from opening.
Expired medication should be disposed of by returning to the dispensing pharmacy.
Any member of staff who is unsure of what to do regarding medication in any given situation should contact their line manager immediately.
2.0 Self-Administering Service Users
Prime Recruitment understands 'self-administering service users' to refer to service users who are responsible for collecting, storing and taking their own medication without any help being required from the organizations staff.
All service users self-medicating must be risk assessed on implementation and thereafter every 3 (Three) months.
Prime Recruitment believes that every service user has the right to manage and administer their own medication if they wish to and are safe to do so.
In cases where there is evidence or suspicion that a self-medicating service user who is failing to comply with their prescription for 72 (Seventy two) hours, or is taking the wrong amounts of a medicine, then the service users self-medication risk assessment must be reviewed and referral to the GP.
No staff member should support a service user with self-administration of medication (creams, eye/ear drops, inhalers) unless they have completed their medication training and competency assessment.
All self-medicating service users should be offered support to maintain and promote their independence i.e.
® the use of compliance aids, such as monitored dosage systems
(where daily medication is set out by a pharmacist into compartmentalized containers)
® Support by staff and responsible others, such as reminders and regular checks.
3.0 Non-Self-Administering Service Users
Prime Recruitment understands 'non-self-administering service users' to refer to service users who require help from organization staff in the collecting, storing and/or taking of their medication. Such help can range from helping a service user to take their medication out of a bottle, packet or monitored dosage system to administering the correct amounts and helping the service user to take it. All such help should be entered into the care plan and agreed with by all parties, including the manager or manager and Care Manager, if required and prior to the help being given.
• Where service users are helped with or have medication administered by staff, those staff should encourage compliance by ensuring that service users take their medication at the time that it is given. Staff should directly observe the taking of medication and medicines should never be left to 'be taken later' unless clearly identified in the risk assessment and care plan. Staff must only sign a _service user's medication chart after the direct observation that medicines have been taken
• Staff must always be aware of the medication being taken by service users and should immediately report any change in condition that may be due to non-compliance to their line manager. The line manager must then discuss the case with the service user's GP and/or nurse, or with the community pharmacist
• A service user has the right to refuse medication and such refusal should be recorded. All such incidents should then be referred back to the prescriber, the service user's GP and/or nurse, or community pharmacist
• Staff may make such efforts to encourage the service user to take their medication as are reasonable and appropriate under the Medication Policy but staff have no right to force service users to take their medication. The use of undue pressure on a service user by any member of staff will be recognized as abuse by the organization and the basis for disciplinary action
• Medical advice should be sought immediately if staff believe that refusal to take medication constitutes a risk to the service user.
4.0 Non-Compliance with Medication
If a service user refuses the prescribed medication:
• Record on the MAR chart that the service user has refused the medication by using the correct code and by two staff members
• Try at a later time to encourage the service user to take their medication
• Inform the line manager or out of hours on-call service user at the earliest opportunity
4.2 Difficulty in Swallowing
If the service user is unable to take the medication because of difficulties with swallowing, the service user's GP must be contacted to inform them of the problem and ask if there are suitable alternatives which can be prescribed or if the medication can be reviewed.
If no suitable alternative formulations are available and the medication is still required, it may be possible to crush the tablet or open a capsule. This MUST ONLY be done following the advice of a pharmacist to ensure that the pharmaceutical properties of the medication are not altered and that it is safe to administer the medication in this way. The advice of the pharmacist, including the name of the pharmacist contacted, must be recorded in the service user's care notes. The method of administration must be agreed by the GP and recorded on the MAR.
4.3 Removal of Medication
Neither the medication(s) nor the MAR should be removed from the service user's home unless asked to do so by the registered manager.
4.4 No MAR chart
If the MAR chart is not available, the medication must not be administered. In the event of newly prescribed medication a MAR chart must be typed as no transcribing by support staff is permitted.
The GP prescribing the medication should be requested to transcribe the medication in order for staff to commence administration. Should the GP refuse they must be informed that administration will not commence. Support staff must notify their line manager alternatively the local out of hours on call manager.
An incident form must be completed and a record made in the progress notes.
4.5 Raising Concerns
Staff should raise any concerns about a service user's medicines with their line manager when:
• the service user is declining to take their medicine
• medicines not being taken in accordance with the prescriber's instructions
• possible adverse effects (including falls after changes to medicines)
• the service user stockpiling their
• medicines medication errors or near misses
• possible misuse or diversion of medicines
• the service user's mental capacity to make decisions about their medicines changes
• there are changes to the service user's physical or mental health
• any other situation that causes concern to the staff member
5.0 Convert Medicines Administration – (Disguising medicines in food and drink)
Disguising medication in the absence of informed consent may be regarded as deception; however, a clear distinction should always be made between those service users who have the capacity to refuse medication and those who do not. Service users who have the capacity to refuse medication should have their views upheld and respected at all times.
Service users who do not have the capacity to accept or refuse medication should be assessed by the manager or manager in conjunction with the GP, consultant, pharmacist, family or relevant service user according to the Mental Capacity 2008 Code of Practice.
As a general principle, by disguising medicines in food or drink the service users are being led to believe that they are not receiving medication when in fact they are. The managers, together with any health professionals involved in the decision to covertly medicate a service user, will need to be sure that what they are doing is in their best interest and that they will be held accountable for that decision having made a Best Interest Decision. To that end, it must be decided and documented that such treatment must be necessary in order to save a life, prevent deterioration or to ensure an improvement in the service user's physical or mental health.
As stated, although it may be necessary to covertly medicate a service user there are only a few circumstances where disguised medication is recognized in law.
The following points must be adhered to:
All documents attached as Appendix
Medicines should not be administered covertly until a best interests meeting has been held. If the situation is urgent, it is acceptable for a less formal discussion to occur between staff, prescriber and family or advocate to make an urgent decision. However, a formal meeting should be arrange das soon as possible
No tablets should be crushed or given covertly ,i.e. hidden in food or drink unless specifically prescribed by the GP and discussed with the pharmacist.
A written signed and dated protocol should be developed which is specific for that service user which gives details of the medication, the strength and dosage, how it is to be disguised, how it is to be covertly administered
The reason for covert ad ministration must be detailed, the name of the prescriber, a start and finish date and a review date
If the authorization is longer than 6 months monthly reviews of the covert medication, involving family and healthcare professionals must be carried out and recorded
Where appointed, a Relevant Service User's Representative (RPR) should be fully involved in any discussions and review so that if appropriate an application for a part 8 review (under DoLS code of practice) can be made, for authorization
Any change of medication or treatment must trigger a review where such medication is covertly administered
This protocol and authorisation must be clearly identified within the care/medication plan (Appendix J)
All document templates must be used to ensure Quality and Compliance in the administration of covert medication:
1. Checklist — DoLS screening document
2. Letter to GP — example (If required)
3. Letter to pharmacist — example (if required)
4. Record of Decision to administer medicines covertly
5. Consent form
6. DoLS application form alternatively Local Authority specific forms
7. MCA Assessment form
6.0 Medication Errors
6.1 Protection of Individuals and staff
From time to time errors can occur in the prescription, dispensation or administration of medicines. The majority of such errors do not harm the service user; however, on rare occasions, they can have serious consequences. It is important that errors are recorded and the cause investigated so that we can learn from the incident and prevent a similar error happening again. Staff must immediately report any error or incident in the handling or administration of medicines. This report should be made to the line manager or out of hours on-call person as appropriate, in order that senior managers are able to take decisions regarding, Regulation 18 of the Care Quality Commission (CQC) (Registration) Regulations
2009. The error report form must also include near misses.
An error is a learning exercise and it is important that within a medication management system, errors are reported so that all can learn from the incident. It is imperative that when dealing with medicines staff are focused and concentrating on the task at hand. Near misses are recorded so that they can be used as empirical evidence for medication training sessions.
Medication errors are regarded as potentially serious events and staff must follow the Royal Pharmaceutical Society Administration of Medicine Guidelines. NICE produce guidelines and quality statements for the administration of medicines in care homes. As an organisation, we follow the good practice from these guidelines as it relates to supported living services.
6.2 Medication error investigations
From time to time, errors can occur when prescribing, dispensing, or administering medicines. Whilst the majority of these errors do not harm the individual, on rare occasions there can be serious consequences. It is important that all errors and near misses are recorded and the cause investigated so that lessons can be learnt from the incident so that measures are put in place to prevent a similar error from happening again. In this organisation we encourage an open transparent way of reporting any errors or near misses to ensure we constantly monitor and improve to prevent further errors.
All medication errors will be investigated and the following will be considered:
a) The experience of staff with regard to any previous incidences/errors
b) The events which participated the error, together with the clinical effect upon the service user
Any of the following events are classified as errors:
a) Medicines are given that are not prescribed
b) Medicines are given at a time other than that prescribed Medicines
c) are given via a route other than prescribed
d) There is an error or omission in recording
e) There is an omission of a prescribed medicine (other than a specifically recorded omission)
The member of staff informs their line manager or out of hours on-call person, then informs the GP or 111 services about the incident and records it on the appropriate form
The GP or 111 services will decide on any medical attention
The manager or manager will investigate the incident, and an appropriate course of action will then be decided upon
The doctor will decide on any medical attention
The manager will investigate the incident, and then decide on an appropriate course of action.
The investigation will be led by a senior staff member who will follow the above criteria and will take place as soon as possible after the event.
Depending on the investigation, the member of staff may require further training, shadowing, or competency assessments. If the staff member is found to be negligent then this may lead to a disciplinary process.
A notification will be sent to CQC, if harm is done, and the local safeguarding unit
The service user and relevant
persons will be informed of the event immediately, either face to face, by phone or email
Near misses that are reported and recorded on an incident report will also be investigated to see what lesson scan be learnt to prevent errors being made in the future
7.0 Controlled Medication
Organizations should be aware that staff are particularly vulnerable when being asked to manage or assist with the management of controlled drugs in a supported living service setting.
A controlled medication bound register is provided in our supported living services. Details of administration should be recorded on the MAR chart and in the Register to ensure correct running totals of medicines, following administration procedures.
Controlled drugs that are no longer required must be returned to the pharmacy for disposal. As good practice if staff have the responsibility of returning controlled medication two members of staff witness the removal and request the pharmacy collecting the returning stock to sign for receipt.
Staff must ensure where possible that controlled medication is administered by two members of staff present and both staff members sign the controlled drug book and the staff member who has administered signs the MAR chart when administered. However, for staff members that lone work and controlled medication is given at a time when two staff members are not present or if this is not convenient or does not match the time stated on the MAR chart the two staff members on handover should complete a stock take and record in the Controlled Drugs register and on the 24hr report form the balance and the staff member lone working can then administer. Staff member on the next shift should also check with the service user that the controlled drug was administered where possible.