MMPOL36 React V4

MMPOL36 Provide Care Solutions and REACT

MM

Management of Medicines in Provide Care Solutions and REACT (Domiciliary Care and Supported Living services)

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Version:

V4

Ratified By:

Medicines Governance & Safety Group

Date ratified:

25/04/2024

Job Title of Author:

Assistant Clinical Director Pharmacy Medicines Medicines Governance & Safety Group

Reviewed by Subgroup or Expert Group: Equality Impact Assessed by: Related Procedural Documents:

Review Date:

and

Assistant Clinical Director Pharmacy and Medicines IGPOL65 Transferring Confidential Information Policy and Procedures MMPOL30 Medicines Management Policy MMPOL33 Medicines Reconciliation Policy MMPOL14 Medical Gas Policy CSPOL01 Complaints and Compliments Policy QSPOL07 Policy for Consent MMSOP61 Standard Operating Procedure for Allergies and Sensitivities to Medicines MMSOP32 Ordering, Storage, Transport and Disposal of Vaccines & Medicines Requiring Refrigerated Storage SOP (Cold Chain) MMSOP28 Standard Operating Procedure for Patient Self-Administration of Medicines MMGUI60 Guidelines for Managing and Supporting Staff following a Medication Error MMPOL31 Controlled Drug Policy MMSOP41Safer Management of Controlled Drugs Suite of SOPs MMSOP67 Standard Operating Procedure for Administration of Medicines within Provides Care Home Services MMGUI74 Self-Care Toolkit for Provide Group Care Services MMSOP56 Standard Operating Procedure for Prompting and Assisting Service Users with their Medicines within the Community 25/04/2027

It is the responsibility of users to ensure that you are using the most up to date document template – i.e. obtained via the intranet.

In developing/reviewing this policy Provide Community has had regard to the principles of the NHS Constitution.

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Version Control Sheet Version V1

Date March 2021

V2

November 2023

V3

January 2024

V4

March 2024

Author Assistant Clinical Director Pharmacy and Medicines Senior Medicines Management Technician / Supported Living Manager/ Care Home Manager/ Domiciliary care Manager Community Health Service Pharmacist

Status New

Review update

and

Community Health Service Pharmacist

Review Update

and

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Comment

Review

General update and Addition of section 19 and 20 General update and Addition of section 3, 7,8,9,16,17

Contents 1.

Introduction ....................................................................................................... 5

2.

Purpose............................................................................................................. 5

3.

Definitions ......................................................................................................... 5

4.

Aims and Objectives ......................................................................................... 6

5.

Responsibilities ................................................................................................ 6

6.

Training and Competency ................................................................................. 8

7.

Supporting Service Users to make Informed Decisions ..................................... 9

8.

Sharing Information ......................................................................................... 10

9.

Ensuring that records are accurate and up to date .......................................... 11

10.

Supply of Medicines (Ordering, Collecting and Storage) ................................. 12

Ordering a Prescription - General principles ............................................................. 12 11.

Disposal of Medicines ..................................................................................... 13

12.

Administration of Medicines............................................................................ 14

13.

Medication Administration Record MAR ......................................................... 16

14.

Homely Remedy.............................................................................................. 22

15.

Covert Administration ...................................................................................... 22

16.

Overt Administration ........................................................................................ 23

17.

Administration of Medication via an Enteral Feeding Tube .............................. 23

18.

Controlled Drugs ............................................................................................. 24

19.

Psychotropic Medication ................................................................................ 25

20.

Cytotoxic medication ....................................................................................... 26

21.

Oxygen ........................................................................................................... 27

22.

Medication Incidents and Errors ...................................................................... 27

23.

Medication handling when service users go out ............................................. 28

24.

Medication Reconciliation ................................................................................ 29

25.

Resources Available to Support Care Staff ..................................................... 29

26.

Risk Management/Monitoring/Audit ................................................................. 29

Appendix 1: Levels of Assistance with Medicines ...................................................... 30 Level 1: General Support, also called Prompting / Assisting with Medicine........... 30 Level 2: Administering Medication............................................................................. 31 Level 3: Administering Medication by Specialised Techniques .............................. 31 Appendix 2: SOP for Use of the Medicines Administration Record (MAR) Chart ........ 32 Appendix 3: Guidance on the Expiry Dates and Storage of Medicines in Care Homes and Supported Living ................................................................................................. 34 Appendix 4: Patient Controlled Drug Collection Form from Community Pharmacy ..... 36 Appendix 5: Patient Returns Form ............................................................................. 37 Appendix 6: List of Controlled Drugs and their Schedules .......................................... 38 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’ .................... 39 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2: ....................................... 41 Page 4 of 42

1. Introduction This policy is intended for management of medicines within Provide Care Solutions and REACT: supported living and domiciliary care services. This policy considers all aspects of managing medicines in Provide Care Solutions and REACT: supported living and domiciliary care services including handling and administering medicines to service users and the provision of care or services relating to medicines.

2. Purpose This policy: • Provides guidance to ensure adults aged 18 and over who receive social care in the community get the support needed to manage their medicines safely and effectively.

• Provides guidance to support safe and consistent management of medicines by authorised staff in accordance with current legislation, national and local guidance which supports the Care Quality Commissions (CQC) Fundamental Standards (2015) and National Institute for Health and Care Excellence (NICE) guidance: Managing medicines for adults receiving social care in the community (2017).

• Supports the provision of Health and Social Care services in relation to medicines for Provide and applies to assistance with medicines in supported living and domiciliary care services for adults over 18 years of age.

• Aims to provide guidance on the safe and secure handling and management of medicines and details the minimum standards of medicines management expected in Provide supported living and domiciliary care settings.

Guidance is provided on the assessment of service user in relation to medicines adherence and support required to enable safe administration of medicines in the community.

3. Definitions Employer Care assessor

Service user

Registered Healthcare Professional

Registered Manager

Provide The person responsible for carrying out the assessment and review of care needs.

This may, for example, be a health professional, social worker or Provide representative (registered manager/senior care staff).

A patient, client or service user is the person receiving care in a domiciliary, or supported living setting.

A registered Healthcare Professional may be a nurse or other professional who has responsibility to provide nursing and/or clinical care to a service user.

A registered manager is a person responsible for the day-to-day running of a care service (domiciliary care or supported living). They are responsible for ensuring Page 5 of 42

Care practitioner/Care Staff/Care worker

Electronic Medicine Records (eMARs)

that the service meets all legal and regulatory requirements, and that it provides quality care for their service users.

A care practitioner/Care Staff/ Care worker provides support to service users who require assistance with their daily living activities due to age, illness, or disability.

They can work in a domiciliary or supported living setting. Responsibilities include personal care, medicines management and meal preparation.

In this policy document- Care worker/ care practitioner will be referred to as care staff Administration Access and Birdie are Mobile and desktop software for managing care delivery, rostering and invoicing. They have a medicines management component which includes a Medicines Administration chart/record.

4. Aims and Objectives • •

•

• •

Ensure that service users’ health, wellbeing and independence is promoted with regards to the management of their medicines, in a manner consistent with the CQC Fundamental Standards.

To support the compliance against the Health and Social Care Act 2008 (Regulated Activities), which includes the proper and safe management of medicines, provide a framework for the consistent safe and secure management of medicines in the supported living and domiciliary setting for Provide staff.

To support the prescribing and use of psychotropic medication for the right reasons and in the right amount for service users and support the STOMP programme ‘Stopping the over medication of service users with a learning disability, autism or both’.

Facilitate collaboration with other agencies who provide care which includes support with medicines in supported living and domiciliary setting.

To provide clear guidance to Provide staff and managers on good practice for the safe management and administration of medicines to service user in their care.

5. Responsibilities Care Assessor It is the care assessor’s responsibility to: • Assess the service user’s care requirements. This includes assessing the level of support with medication the service user requires. (See Appendix 1 “Levels of Assistance”).

• Stipulate the level of support to be provided in the care plan and on the care assessment.

• Take into consideration, when assessing care needs, any factors which may require more time to be completed safely.

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• • • •

Ensure that a review is conducted whenever there is a change in the service user’s circumstances which may affect the level of support required, or, as a minimum, every year.

Ensure that all providers of care, including Day Care, Respite, Domiciliary, Supported Living and Home and Community Support are aware of the service user’s care needs.

Liaise with family members and other informal carers.

Seek consent according to Provide consent policy (QSPOL07 Policy for Consent).

Service Managers (Registered manager/assistant manager) The service manager is responsible to ensure that all staff have the knowledge of this policy and are trained in all aspects of medicines administration and safety relevant to their role.

The service manager will be accountable to provide assurance to Provide Group Quality and Safety Committee of compliance with this policy.

The service manager is responsible to ensure that the necessary Standard Operating Procedures (SOPs) are in place, staff are trained in their use, monitored and reviewed.

Care Staff (Care Practitioners / Care Worker) It is the responsibility of Care Staff to: • Follow the care plan and this policy with meticulous care and attention.

• Provide the level of support specified in the care plan.

• Give level 1 support (e.g., prompting/assisting) in accordance with the care plan and the service user’s instructions.

• Give level 2 or 3 support in accordance with the care plan, the prescriber’s instructions and involving the service user in their care where able to do so.

• Meticulously follow the procedure contained in “Instructions for use of Medicines Administration Record (MAR) chart by care staff” when administering medicines (Appendix 2).

• Record the medicines support given to a service user for each individual medicine on every occasion, in line with Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This includes details of all support for prescribed and over-the-counter medicines, such as: • reminding a person to take their medicine or helping them remove it from the packaging • giving the person their medicine • recording whether the person has taken or declined their medicine.

• Be alert to any factors which may pose a risk to the service user, and to report any concerns to their manager or the care provider’s designated responsible person.

This may include concerns about the availability or accuracy of the MAR chart.

• Immediately report any refused doses or mistakes in the administration of medication to their manager, including omitted doses. If unable to contact the manager, the care staff should not delay seeking medical advice.

• Act in a way which would not put themselves or the service user at risk.

• Ensure they have received the necessary training and are competent and confident to provide the care required.

• Provide staff are only accountable for medication they themselves administer or assist with.

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Registered Healthcare Professional It is the responsibility of the registered healthcare professional when asked to support with a service user in Provide Care solutions to: • • • •

Carry out a health assessment.

Provide nursing or clinical care to the service users. This includes caring for wounds and pressure sores and carrying out invasive procedures such as injections and use of catheter maintenance solutions.

Monitor the health status of the service user and report any changes to the service user’s GP as appropriate.

Adhere to their professional practice guidelines.

6. Training and Competency • •

• •

All Provide staff assessing a service user’s medicines support needs must have the necessary knowledge, skills and experience to ensure safe medicines management.

Training for Provide non-registered staff working for supported living and domiciliary care is provided through Provide Learning and Development and must follow the NICE pathway: Managing medicines for adults receiving social care in the community - NICE guideline [NG67].

All staff for supported living and domiciliary care services will complete medicines training as directed by the Head of Talent and Learning for Social care.

Robust processes must be in place for social care providers with responsibilities for medicines support to ensure staff are trained and competently assessed to ensure that they: • Receive appropriate training and support.

• Have the necessary knowledge and skills.

• Are assessed as competent to give medicines support being asked of them, including assessment through direct observation.

• Have an annual review of their knowledge, skills and competencies.

Level 1 Support (See Appendix 1 for details of the levels of support) • •

Any staff providing level 1 support with medication must clearly understand the limits of the support to be provided and work strictly within the instructions in the care plan.

If they have any concerns regarding this, or the service user appears to require a greater level of support, the care staff must report this to their manager promptly.

Level 2 Support •

•

Care staff must not be permitted to give level 2 support with medication until they have: • Received training in medicines management.

• Been assessed as competent.

Competencies should be assessed consistently and re-assessed annually.

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Level 3 Support •

• •

This level of support will normally be administered by a healthcare professional.

However, if appropriate a healthcare professional may delegate these tasks to named care staff provided: they agree this with the Registered Manager; the healthcare professional personally provides the required extra training; and is satisfied that the care staff are competent. On-going support for the care staff is required from the delegating health professional as ultimate responsibility for these tasks remains with the healthcare professional. The Registered Manager will keep a record of this agreement and ensure it includes: • A local agreement between health and social care that this support will be provided by a care worker • Evidence that consent is given by the service user (or their family member or carer if they have lasting power of attorney) • The responsibilities of each person are agreed and recorded • Evidence that care staff are trained and assessed as competent (see also the section on training and competency).

Competency should be assessed at least annually.

The healthcare professional remains accountable for the task. A record of such delegation must be retained by the provider and the healthcare professional.

In addition to having sufficient numbers of suitably trained care staff, Provide will demonstrate appropriate quality assurance systems to record and monitor the effectiveness of medicines management training.

These will include: • lists of all staff who have received training and when.

• records of the initials of staff who will record on medication administration record charts or able to provide an electronic audit trail if eMAR is used. Where eMAR is used, each staff must have their own login and should not share logins.

• a central system for recording medication incidents, including referrals to Safeguarding as needed (refer to section 22 on details on medication error incidents) • regular auditing of MAR/eMAR charts • regular internal assessment of services medicines management processes.

7. Supporting Service Users to make Informed Decisions Care staff in every setting should ensure that service users should have the same opportunities to be involved in decisions about their treatment and care as people who are not receiving care, and that they get the support they need to help them to take a full part in making decisions.

Care staff should identify and record anything that may hinder a service user giving informed consent. Things to look out for include mental health problems, lack of (mental) capacity to make decisions, health problems (such as problems with vision and hearing), difficulties with reading, speaking or understanding English and cultural differences. These should be taken into account when seeking informed consent and should be regularly reviewed.

If there are any concerns about whether a service user is able to give informed consent, care staff should escalate to their senior colleagues or registered manager who can support or ensure they: Page 9 of 42

• • • • • •

Record any assessment of mental capacity in the service users care plan and records.

Involve service users in best interest decisions, in line with the Mental Capacity Act. Find out about their past and present views, wishes, feelings, beliefs and values.

Involve them, if possible, in meetings at which decisions are made about their medicines.

Talk to people who know them well, including family members or carers (informal or unpaid carers) and friends, as well as care staff.

Deliver care and treatment in a way that empowers the service user to be involved in decisions and limits any restrictions to their care.

8. Sharing Information Staff should ensure they follow process for sharing accurate information about a resident's medicines, including what is recorded and transferred when a resident moves from one care setting to another (including hospital).

The following information should be made available on the day that a resident transfers into or from a care setting: • Service users’ details, including full name, date of birth, NHS number, address and weight.

• GP's details.

• details of other relevant contacts defined by the service user and/or their family members or carers (for example, regular community pharmacy) • known allergies and reactions to medicines or ingredients, and the type of reaction experienced.

• Medicines the resident is currently taking, including name, strength, form, dose, timing and frequency, how the medicine is taken (route of administration) and what for (indication), if known (This should include any complementary therapies and over the counter medication if known).

• changes to medicines, including medicines started, stopped or dosage changed, and reason for change if known.

• date and time the last dose of any 'when required' medicine was taken or 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 service users’ needs to carry on taking the medicine (adherence support) if known.

• what information has been given to the service user and/or family members or carers in relation to their medicines.

• details of the person completing the transfer/ acceptance (name, job title) and the date are recorded.

When new service users are received into the service, care staff should check that complete and accurate information about the service users medicines has been received and recorded, and is acted upon in timely manner.

Where PROVIDE has responsibilities for medicines support for service user this would have been assessed and documented in their care plan. Care staff may be required to communicate and share information about medicines (take account of the service user's expectations for confidentiality).

This includes communication with: • the service users and their family members or carers • care workers and other social care staff Page 10 of 42

• health professionals, for example, the service user's GP or supplying pharmacist • other agencies, for example, when care is shared or the service user moves between care settings.

If a service user has cognitive decline or fluctuating mental capacity, ensure that the service user and their family members or carers are actively involved in discussions and decision-making. Record the service user's views and preferences to help make decisions in the service user's best interest if they lack capacity to make decisions in the future.

9. Ensuring that records are accurate and up to date The service users care plan should detail the level of assistance required with medication.

The risk assessment will also give additional information. Both of these should be consulted by care staff prior to support or administration of medication. The care plan and MAR/eMAR chart are a confidential record which should only be shared with others on a professional basis and with permission from the service user, referring to the Mental Capacity Act when necessary.

Staff must record the medicines support given to a service user on every occasion. This includes details of all support for prescribed and over-the-counter medicines, such as: • reminding a service user to take their medicine • giving the service user their medicine • recording whether the service user has taken or declined their medicine Recording of any medicines support that care staff give to a service user can be done on paper or electronically on Access or Birdie depending on the service they work for.

Ensure that medicines administration records include: • the service user's name, date of birth and any other available person-specific identifiers, such as the service user's NHS number • the name, formulation and strength of the medicine(s) • how often or the time the medicine should be taken • how the medicine is taken or used (route of administration) • the name of the service user's GP practice • any stop or review date • any additional information, such as specific instructions for giving a medicine and any known drug allergies.

When a family member or carer gives a medicine (for example, during a day out), agree with the service user and/or their family member or carer how this will be recorded. Include this information in the care plan.

Information in the service user care plan and medicines administration record should be regularly reviewed and ensured that it is up to date and the most accurate version. Where changes have been made to a service user medication, these updates should be acted upon promptly and records of what information was received and action is kept in service user records.

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10. Supply of Medicines (Ordering, Collecting and Storage) Ordering a Prescription - General principles • • • • •

This is not a routine task completed by care staff. Responsibility for ordering medicines usually stays with the person and/or their family members or carers.

Prescriptions will only be ordered as part of the agreed Care Plan.

Details of what management of medicine is needed will be agreed between the service and the service user after an assessment has been completed.

The Service User must give consent for the prescription to be ordered.

Where the Service User lacks capacity, a best interest decision may be required if there is no one to legally consent on their behalf.

A consent form must be completed and signed by the service user giving consent to contact their GP practice and Community pharmacy on their behalf and discuss their medicines so that prescriptions can be managed.

Where staff are responsible for ordering a service user's medicines, they should not delegate this task to the supplying pharmacist (or another provider), unless this has been requested and agreed with the service user and/or their family members or carers.

Records must be kept in such a way that other care staff are aware of what has been ordered or collected. Where there is a discrepancy, this is addressed in a timely manner.

Collection and Receipt of Medication Domiciliary Care and Supported Living • •

Care staff may collect medicines only if this is specified in the care plan (See Appendix 4 for collection form to be completed).

Care staff may assist with the prescription request only if specified in the care plan.

All assistance in obtaining the medicines must be recorded in such a way that other care staff are aware of what has been ordered or collected.

Supported Living • • •

Care staff may assist with the prescription request only if specified in the care plan.

All assistance in obtaining the medicines must be recorded in such a way that other care staff are aware of what has been ordered or collected.

Medications are booked in by staff, checking the medicines collected are correct and correspond with the order placed.

The MAR chart is written by trained staff for the coming months medication and double checked by a competent member of staff.

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Storage of Medication Domiciliary Care • • • •

•

Medicines must be stored where they are readily accessible to all carers, subject to the Medicines Risk Assessment.

Medicines should be kept out of the reach and sight of children and others to whom they may pose a risk.

Medicines should be kept away from sources of heat, light and damp.

Where the product label or packaging specifies defined storage conditions, e.g., refrigeration, this must be followed. If it becomes clear that the specified storage conditions have not been adhered to, the carer or their manager should seek advice from the pharmacy, dispensary, or medicines management team regarding the medicine’s suitability for use.

All medicines must be kept in the packaging in which they were obtained from the pharmacy or dispensary.

Supported Living • •

•

A clear audit process must be recorded, and assessment carried out for receipt of medication into the home’s own storage and transfer to the service user’s individual storage.

One key must be given to the service user (if appropriate) and a spare key (which is labelled) must be kept securely in the medication room. Loss of a service user’s key must be reported to the manager who will decide if a new lock is fitted for safety.

The senior carer must also make sure that the service user’s medication cupboard is cleaned on a four weekly basis and recorded on the Temperature/Cleaning Chart.

11. Disposal of Medicines Dropped and single dose disposal • • • •

Dropped tablets can be avoided with good administration technique e.g. preparing doses over a work surface. In the event that a tablet is dropped, the care staff should assess the situation and ask if they want a new dose prepared.

If medicines are disposed of a note should be made in the daily record of what medicines have been returned to the pharmacy.

Care staff should not dispose of any medication in household waste or by flushing down the toilet. A small container may be used to return single doses to the pharmacy or dispensing surgery.

If doses of medication are disposed of, a new prescription may be needed to replace these doses, which the care worker should arrange via their manager.

If care staff remove medicines for disposal, the names and quantities should be recorded, and a copy retained with the care record. (See Appendix 5 for returning controlled drug medication to pharmacy form.)

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Domiciliary Care • •

•

Medicines belong to the service user for whom they were prescribed and cannot be removed without their permission.

Service users are responsible for disposing of their own medicines safely unless specified in the care plan/medication risk assessment. Care staff may only undertake this task if the patient is unable and there are no relatives or other informal carers to do so. In such circumstances the medicines must be taken directly to the pharmacy or dispensary.

If medicines require disposal, then care staff should store these separate from other medication being used in a safe place and alert the service user or relative. The service user or relative should be encouraged to return unused or unwanted medicines to a pharmacy for disposal as soon as they are no longer required or have expired.

Supported Living Services • •

•

12.

• • •

• • • •

Medicines belong to the service user for whom they were prescribed and cannot be removed without their permission.

Service users are responsible for disposing of their own medicines safely unless specified in the care plan/medication assessment. Care staff may only undertake this task if the patient is unable and there are no relatives or other informal carers to do so. In such circumstances the medicines must be taken directly to the pharmacy or dispensary.

Before disposing of a medicine that is still being prescribed for a service user, staff should find out if it is still within its expiry date and if it is still within its shelf-life if it has been opened (See Appendix 3 for further information on expiry date).

Administration of Medicines Service users should self-administer their medicines whenever possible and appropriate.

Medicines must only be administered in accordance with the prescriber’s specific instructions.

Care staff may only assist with administration of medicines that are correctly labelled by a pharmacy or dispensary with the service user’s full name and date of dispensing. The medicine name, prescribed dose and frequency should also be included except where the dose is variable and given in accordance with separately written instructions e.g., warfarin.

Tablets must not be crushed or dissolved, or capsules opened unless this is stated on the dispensing label, or written instructions received from a healthcare professional.

Medicines must not be given after their expiry date. Note: many medicines have a reduced expiry date after opening (See appendix 3). Check pack for details. If in doubt, refer to pharmacist for advice.

If oral liquid medicines need to be measured via a syringe, a designated oral syringe must be used.

Care staff must pay due regard to service users’ privacy, dignity and religious/ cultural beliefs at all times.

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• • •

Service users have the right to refuse their medicines and must never be coerced to take them.

Care staff must be mindful of medication which is time sensitive to avoid omitted/delayed dose e.g., Parkinson medication.

The procedure for administration of medicines is included in the “Instructions for use of Medicine Administration Record (MAR) Chart by Care staff” (Appendix 2).

Monitored Dosage Systems • •

Monitored dosage systems (MDS) supplied by a pharmacy should only be used as an aid to compliance for the service user to self-administer. Any support offered by care staff under these circumstances would be restricted to prompt (level 1).

Care staff who administer medicines are expected to be able to individually identify each medicine they administer and record it separately on a MAR chart. Therefore, MDS are rarely considered appropriate when giving level 2 support.

N.B. Any selection of tablets from a MDS, including selecting and/or opening a particular section, is considered to constitute level 2 support.

There may, however, be a limited number of situations in which, upon Medicines Risk Assessment and following consultation with a member of the medicine’s management team, it is considered appropriate for care staff to administer from a MDS. In this case a MAR chart must also be used.

• •

Some MDS systems (usually only available to care homes) may have one medicine per “blister” and each blister has a direction label. These may be treated as if they were original packs.

In domiciliary care settings it is desirable that all medicines are supplied in the pharmacist’s original container, complete with label and patient information leaflet, rather than in monitored dose packs.

Care staff should also Refer to MMSOP67 Standard Operating Procedure for Administration of Medicines within Provide Care Solutions

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13. Medication Administration Record MAR General principles Medication must be administered in a person-centred way and respecting dignity, independence, privacy, cultural and religious beliefs of the service user at all times.

The 6 Rights of Administration must be applied at all times:

Right Service user Right to Refuse

Right Medicine

Right Time

Right Route Right Dose

In order to have ‘capacity’ to manage medication, the service user must be able to: • • • •

understand how to take their medication and understand why the medication has been prescribed. understand what will happen if they don’t take the medication or not following the GP’s instructions. retain and use the information. make choices and be able to tell people about them.

Staff need to ask for the service user’s consent each time medication is to be taken: •

Where possible, the service user must provide informed consent. If that is not possible, but there is a possibility that the service user can give consent, then the service user must be supported to make an informed decision.

• If consent cannot be obtained or the service user lacks capacity, key people acting in the best interests of the service user can make a decision. This must include a full assessment from a healthcare professional. Documentation must be kept of how and why the decision was reached and their competence assessed before this task is undertaken and clearly recorded in the service user’s care plan.

• instructions must be sought from the GP. In such cases, the service user’s ‘Care Plan’ must be referred to.

Service users must be given the choice:

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•

•

To take or refuse medication. If refused, the circumstances/reason (if provided) must be recorded in the service user’s care plan and MAR/eMAR, unless an agreed plan of action is already in place for when medication is refused, staff should follow information in the patient information leaflet (PIL) for any missed doses unless there are specific instructions from the GP. The GP must be contacted for advice after consistent refusal, involving the service user where appropriate and obtaining consent where able to.

Where the medication is administered,e.g. if a service user who self-administers wants to have their medication in the lounge, the medication must be taken from their room and taken directly to the service user with no distractions going to/coming back from the service user’s room. Do not try to dispense more than one service user’s medication at any given time. Once administered, the MAR/eMAR must be updated immediately.

Purpose of the MAR/eMAR chart •

•

•

The MAR/eMAR chart is the confidential, formal record of administration of medicines and may be used as evidence in clinical investigations and court cases.

It is therefore important that they are clear, accurate and up to date. MAR chart can be a paper record or an electronic record.

Care staff must record the medicines support given to a service user for each individual medicine on every occasion. This includes details of all support for prescribed and over-the-counter medicines, such as: - reminding a person to take their medicine or helping them remove it from the packaging - giving the person their medicine - recording whether the person has taken or declined their medicine The MAR/eMAR chart must provide an accurate account of the medicines being administered to the service user by the care staff. It should document all prescribed medicines, including externally applied medicines.

Responsibilities of the Manager for MAR/eMAR charts It is the responsibility of the manager to: • Ensure a MAR chart is available by providing a paper MAR chart or an electronic MAR for staff to record all medicines support given to a service user for each individual medicine and on every occasion. A new chart is required each month.

• Set up a system to assure the source and accuracy of information contained in the MAR/eMAR chart, and any changes.

• Establish a system by which any changes made after production are evident, i.e., dated, signed and indicates who has made the change.

• Establish an effective system to ensure that any MAR/eMAR charts which are no longer in use (e.g., from previous months) are removed promptly from the premises (domiciliary care) and stored appropriately.

• Establish an effective system to ensure that the MAR/eMAR chart is reviewed following discharge from hospital and is updated when changes are made to the service user’s medication, e.g., following an out-patient appointment.

Safe production of MAR/eMAR charts The procedure for producing MAR charts should ensure that: • The MAR/eMAR chart is individual to the service user and reflects the items which are still being currently prescribed and administered.

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• • • • • • • • •

The MAR/eMAR chart is clear, indelible, permanent and includes the product name, strength, dose and frequency.

The MAR/eMAR chart is constructed on the basis of currently prescribed medicines together with information about repeat prescriptions for PRN medicines.

The MAR/eMAR chart includes all prescribed externally applied medicines to be administered by care staff.

The MAR/eMAR chart incorporates a method to ensure that any changes made after production are evident (dated, signed and indicates who has made the change) There is a robust system in place to ensure timely removal from the MAR/eMAR chart of items no longer prescribed or administered, following documented communication to this effect from the prescriber.

When medicine formulations are changed, for example from a tablet to a liquid version, that the original item is removed from the current and all future MAR/eMAR charts for that service user.

When a medicine is included in a MAR/eMAR chart as two or more differing strengths, these should be placed next to each other on the same MAR chart where appropriate and possible, to help minimise errors.

When a short course of medicine is prescribed, the MAR/eMAR chart is clear that this is the case.

If an electronic MAR chart cannot be accessed that an accurate written MAR chart is made available.

Contents of MAR/eMAR charts The MAR/eMAR chart must detail: • The service user’s details • Known Allergies/ Sensitivities • The name and form (e.g., tablets, capsules) of ALL medicines that are to be administered or applied by the care staff.

• The time they must be given.

• The day of the week, if not daily • The dose • The route, if not to be taken by mouth, e.g., “to be inhaled”.

• Any important special information • The names of those preparing and checking the MAR/eMAR chart and the date prepared.

• If more than one chart is in use, reference to the other charts, e.g., “chart 1 of 2”.

• This information must exactly match that on the dispensing label provided by the pharmacy or dispensary.

Use of MAR/eMAR charts See “Instructions for use of Medicine Administration Record (MAR)/electronic MAR Chart by Care staff” (Appendix 2) • Each time a dose is due, the care staff giving it must follow the instructions step by step.

• They must immediately record administration of a dose by signing the MAR/eMAR chart in the correct place. The time of administration should be recorded in the care

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• • •

notes, if the actual time administered is not specified, or differs from that on the MAR chart or electronic MAR. Any prescribed medicine not given must be clearly recorded as set out in the instructions, and the reason documented.

The information on the MAR/eMAR chart will be supplemented by the service user’s care plan.

It is important that any MAR/eMAR charts which are no longer in use (e.g., from previous months) are removed /archived medication folder or on the electronic system.

As Required (PRN) Medication Domiciliary Care and Supported Living Care staff are not permitted to assist with these medicines unless there are specific instructions which clarify: • What the medicine is being used for e.g., Pain • The minimum interval between doses • Maximum number of doses in 24 hours • Quantity of medication to be given (dose) • The MAR chart should also include a review date if known.

• The Care Plan should have clear instructions detailing: • Whether the medicine should be offered at regular intervals to the service user, or only in response to a request from the service user.

• Any further useful information.

Care staff should: • Refer to their manager if this information is not available.

• Always check the time of the previous dose in order to ensure that it is within the minimum time interval specified by the prescriber.

• Check the service user has not taken the medicine themselves or been given it by an informal carer since the last documented dose.

• Record the date and time the dose was administered.

• Inform their manager, who should contact the service user’s doctor, if • The service user wishes to take PRN medication more frequently than prescribed.

• Consumption increases markedly.

• They have reason to believe the medication is not effective for the service user.

• They have reason to believe the medication is no longer required.

• Record additional information (such as reason for administration of the medicine) in the care record.

• It is good practice to record the current balance remaining after each dose has been administered, when practical. This will facilitate good stock management and audit and deter diversion.

• If PRN medicines are used infrequently, it is important to check before administering: • That it was originally prescribed for the purpose for which it is now required • That the service user is not taking any new medication that might interact with or duplicate it. If in doubt, check with the doctor or pharmacist.

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• •

That it has not been replaced by a different prn or regular medicine more recently prescribed That the supply is still in date, bearing in mind that some medicines have a shortened expiry date once opened (see Appendix 3). Check pack for details. If in doubt, refer to pharmacist for advice.

Variable Doses Patient/ Service User Choice If a variable dose is prescribed (e.g., one or two tablets to be taken if required for pain) the decision regarding the dose to take rests with the service user and the prescriber.

Care staff must: • Ask the service user how many they wish to take. If the service user is unable to decide or respond the care provider should request specific written instructions from the prescriber • Care staff are not permitted to assist with these medicines unless and until a decision has been made regarding the dose to be taken, by the service user or the prescriber.

• Clearly record on the MAR/eMAR chart the number of tablets taken

Warfarin • • • • •

•

The dose of warfarin varies according to results of a blood test.

It is important to take great care that the correct dose is given, according to the most recent instructions which should be available in the service user’s yellow book, or other anticoagulant record.

The MAR/eMAR chart must be initialled when dose given, as normal, but in addition the dose given in milligrams (mg) must be written below the carer’s initials. This should also be recorded in the care record.

As part of the risk assessment, managers should ensure they know who to contact in case of queries regarding current dose etc.

If the yellow book or other anticoagulant record is not available or not up to date care staff should refer to their manager who should urgently seek clarification. If unable to obtain clear instructions from a healthcare professional, the manager should instruct the member of staff to continue according to existing dosage instructions until clear information can be obtained, ideally within 24 hours.

Care staff should be vigilant and aware of arrangements for individual service users.

Changes to Medication • •

The manager must ensure there is a system in place to check the source and accuracy of any changes. A cross reference to the care record is recommended.

When a service user’s medication is altered, the manager is responsible for ensuring the MAR/eMAR is amended as follows: • The original direction is cancelled.

• The new directions are written legibly and in ink on a new line of the MAR printed label / electronic MAR. • The entry is signed and dated (including a witness when possible).

• The date received from the pharmacy or dispensary is recorded on the MAR/eMAR. Page 20 of 42

•

Alternatively, a new MAR/eMAR chart may be produced with the correct ‘start date’ clearly stated.

Discharge from Hospital • • •

•

When service users leave hospital, even following a short stay, it is likely that changes will have been made to their medicines.

The manager must ensure there is a system in place to review and update the MAR chart following discharge from hospital.

The labelled supply sent home with the service user is the authority to administer those medicines and supersedes any previous MAR/eMAR chart. Therefore, if the MAR/eMAR chart is not yet available, medicines should be administered according to the instructions on the label, and all doses given must be recorded in the care record, with full details of: • Medicine name • Strength • Dose • Time and date administered.

• The fact that the dose was administered.

• Signature of the care staff.

The updated MAR chart must be made available as soon as possible.

Verbal Instructions to change medication or doses.

Care Staff may only assist with medication according to written instructions, except in the following cases: • Under exceptional circumstances an individual care staff may accept verbal instructions to change, or stop, one day’s treatment only from a doctor or other healthcare professional caring for the service use.

• Only the individual receiving the instruction first hand from the doctor or other healthcare professional may act upon this instruction.

• Verbal instructions must not be passed on for action by any other care staff. Written confirmation must be received before others are permitted to carry out the new instructions.

• Under exceptional circumstances the manager may pass on verbal instructions to change, or stop, one day’s treatment only to care staff, if the prescriber is unable to do so directly, provided.

• The manager receives the instruction first hand from the doctor or other healthcare professional and carefully records the details of the conversation, and only the individual care staff receiving the instruction directly from their manager may act on the instruction.

• Email evidence for changes in medication to GP to follow up on 111 advice.

Care providers should: • Request the prescriber/GP to follow up verbal instructions in writing as soon as possible.

• Ensure that verbal instructions are fully documented in the care record.

• Ensure that the person completing the record: • Reads their instruction back to the authorising doctor or other healthcare professional as a double check, preferably in the presence of the service user.

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• • • • • •

Sign and date the record and ask the witness to do the same.

Records the time and date of the conversation.

Records the name of the authorising doctor or other healthcare professional.

Involves the service user as much as possible to ensure they are aware of and consent to the change and can check the actions of care staff.

Records the dose given in the care record with a cross-reference in the MAR/eMAR chart to the care record, (e.g., “see care record”) Ensure that the MAR chart is not amended, as this applies to a single day’s treatment only.

Retention of records, including MAR/eMAR charts • • •

The paper MAR chart must be retained in the service user’s home while in use.

Any paper MAR charts which are no longer in use (e.g., from previous months) must be removed promptly from the premises.

Used MAR charts/electronic MAR must be retained by the provider for a minimum of 8 years.

14.

Homely Remedy

Over the Counter Medicines purchase Whilst the purchase of medicines or herbal or alternative therapies may take place if requested, medical or pharmaceutical advice should be sought before or at the time of the purchase, in order to reduce the risk of interactions with prescribed medicines. The community pharmacist can also give advice if they are provided with details of all of the service user current medication.

• Care staff must not give any assistance with the administration of these medicines unless this has been updated in the care plan.

• The use of over the counter medicines, when known, must be documented, and considered in the initial and ongoing ‘Medicines Assessments’ and care plan.

As with all prescribed medication any medication that is given as a homely remedy must be recorded on the MAR chart. It should also be recorded in the service users’ notes.

The MAR chart entry should include: • The name of the preparation • The reason it is being used.

• The dose which has been administered • The frequency and the maximum daily dose which should be administered.

15.

Covert Administration

The covert administration of medication is the practice of hiding medication in food or beverages so that it will be undetected by the service user receiving the medication.

Medication may be crushed or medication in liquid form may be used. This practice exclusively applies to service users who are not capable of consenting to treatment. It is sometimes necessary and justified but should never be exercised with service users who are capable of deciding about their medical treatment.

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Covert administration of medicines must only be considered in exceptional circumstances, following discussion with family members, health and social care professionals etc. as appropriate, taking into consideration the capacity of the service user to consent or refuse treatment, and documented in the ‘Medicines Risk Assessment’ and the care plan. Advice must be sought from a doctor pharmacist regarding the pharmaceutical suitability of the medicine for administration in this way.

Medication must never be crushed, broken or mixed with food and drink unless specifically directed to do so by the prescriber. Decisions to administer medicines covertly must not be taken by any individual in isolation. All decisions of this nature must clearly define who should be involved in, and responsible for, decision-making and in accordance with Department of Health guidance and the Mental Capacity Act (MCA). They must be fully documented as set out in the MCA code of practice.

16.

Overt Administration

“Overt” administration is often confused with “Covert” administration (see section above for when covert administration applies).

“Overt” administration refers to when a medication manipulated to make it more palatable for the patient, the medication is added to food or drink and is done with the patient’s consent, this may be required when a patient is having difficulty swallowing.

Care staff should only crush tablets or open capsules on the direction of the prescriber, following instructions in the patient’s medicines administration record (MAR) chart or care plan.

Care staff should communicate and consent service user as you would any other process of their care. Let the service user know you are crushing their medication or opening a capsule and mixing it with food so it is easier for them to swallow, It is sometimes also easier to prepare them by letting them know it may alter the taste of the food and the importance of finishing the food, so they get the full dose. However, they have the right to refuse.

17.

Administration of Medication via an Enteral Feeding Tube Enteral feeding tubes provide access to the stomach or small intestine. They are used in cases where there is an obstruction or where a service user has difficulty in swallowing.

The main types of enteral feeding tubes are: • Nasogastric (NG): a tube passed through the nose directly into the stomach.

• Percutaneous Endoscopic Gastrostomy (PEG) or radiologically inserted gastrostomy (RIG): a tube inserted through the abdominal wall directly into the stomach.

• Nasojejunal (NJ): a tube passed through the nose directly into the jejunum (small intestine).

When a service user has an enteral feeding tube in place, it may be necessary to alter the form of a medication so it can be given down a tube. Crushing or opening capsules must not be a routine practice, and Staff must ensure that they have had adequate training and there is appropriate documentation in place before medication can be altered in this way.

Verbal communication from a GP to open or crush medication is not sufficient. The care staff MUST be provided with written documentation from the GP – in practice this can be Page 23 of 42

addition to the dosage instructions on the prescription form, which the pharmacy adds to the label and the MAR chart. The instructions should then be documented in the care plan.

Administration of medication via an enteral feeding tube will be classed as Level 3 activity.

These types of medicines will normally be administered by a healthcare professional.

However, if appropriate a healthcare professional may delegate these tasks to named care staff provided: they agree this with the Registered Manager; the healthcare professional personally provides the required extra training; and is satisfied that the care staff are competent; once trained and assessed as competent will undertake the delegated task as per agreed process. Care staff should be given the opportunity to refuse to administer medications via specialist techniques if they do not feel confident in their own competence.

If delegation is not possible, the onus is on the service to ensure continuity of care.

The care staff must not administer medication via an enteral feeding tube until they have been assessed as competent by the named registered healthcare professional and supervision has been recorded.

The Healthcare professional delegating the task will remain accountable for the delegation of any aspects of the task and ensuring the individual is competent to carry out the task.

This includes ongoing assessment and supervision of practice.

18.

Controlled Drugs

Controlled Drugs (CDs) are prescribed and dispensed for individually named service users, in the same way as other prescription medicines. However due to the special legal requirements extra time should be allowed for prescriptions to be written. Prescriptions that do not comply with the legal requirements may have to be sent back to the prescriber for altering before they can be dispensed. See Appendix 6 for list of CDs and their schedules.

• CDs will be received and stored in the same way as all other prescribed medicines.

• All staff involved with checking and administering the CD must be trained and assessed as competent to administer medication.

• Administration of the CD must be recorded on the service user's task on eMAR or paper MAR and documented in the Care visit record.

• Service Users not requiring support with medication will keep and take CDs themselves. Care staff must report if Service Users are leaving any medication lying around, including any known to be a CD, where they may be a risk to others and may be at risk of being stolen.

• The risk assessment process places responsibility on the Service User who keeps the CDs. Monitoring and review of the risk factors must take place and where there is a change in the Service User's condition or concerns about capacity, this must be reported. A review following the principles of the Mental Capacity Act 2005 must then take place.

• Service User's medication can only be disposed of with their consent. Responsibility for the safe disposal of medicines (including tablets, capsules, eye drops, tubes of cream, patches etc.) rests with the Service User, their family, or the person identified in the medicines Assessment • Where medication administration support is given, staff may need to make arrangements for the medication to be returned to a local pharmacy.

• This will have been agreed with the service user and details will be in the care plan.

• The returns for must be completed and signed by the pharmacy staff when returning medicines for disposal.

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19.

Psychotropic Medication

Psychotropic substances are often used as a chemical restraint. These are chemical substances that alter brain function, resulting in temporary changes in perception, mood, consciousness and behaviour. These include groups of medicines such as antidepressants, antipsychotics, antiepileptics, mood stabilisers (including sodium valproate and carbamazepine), anxiolytics (benzodiazepines), and central nervous system stimulants. They are used in service user with a learning disability and/or autism. These medicines may need regular monitoring. They can cause side effects that affect service users’ physical health.

Psychotropic medicines are sometimes used to control how a service user behaves or to restrain them (where justified for purposes set out within the legal framework). This could be because staff do not know how to communicate with a service user or to meet their needs to maintain a good quality of life. Psychotropic medicines should only be used as the least restrictive option. They must be included in the service users’ care plan.

STOMP stands for stopping overmedication of people with a learning disability, autism or both.

STOMP is a national project to reduce prescribing and administration of psychotropic medicines. It is about helping service user to stay well and have a good quality of life.

Psychotropic medicines should only be considered if: • psychological or other interventions, such as treatment for any coexisting mental or physical health problem have not helped to improve the service user’s quality of life or • the risk of harm to the service user or others is very severe.

PROVIDE will ensure it: • Follows best practice recommendations and national guidelines. For example, NICE NG10 Violence and aggression: short-term management in mental health, health and community settings.

• Assess service users’ capacity to make decisions about their medicines.

• Act in a way that is proportionate, pragmatic and safe.

• Include when medicines might be used in person-centred behavioural care planning.

Keep clear records of behaviour that staff find difficult to manage. Identify themes and triggers. Put environmental and psychological support in place to reduce distress, improve communication and quality of life. Using a medicine should be the least restrictive option.

• Provide accessible medicines information. Explain the risks and benefits of taking a psychotropic medicine. This supports shared decision making.

• If medicines are prescribed to be administered when required, it must be clear when it might be needed and the expected outcome. Evaluate and record the outcome of giving a when required medicine to make sure it is having the required effect.

• Managers should ensure staff are knowledgeable about psychotropic medicines. Staff should be able to identify potential side effects from taking a medicine. Healthcare advice should be sought if needed.

• Work collaboratively with healthcare staff and share information. Support service user to access medicines reviews, physical health checks and therapeutic medicine monitoring.

• Manger will need to report the numbers of service user who have had their behaviour controlled or restrained by medicines to CQC. Use the adult social care provider information return.

See MMSOP71 Standard Operating Procedure STOMP for more information.

All staff must follow SGPOLCORE22 – Learning Disability and Autism Policy v1 Page 25 of 42

20.

Cytotoxic medication

A cytotoxic or cytostatic medicine is defined as any medicinal product that possesses anyone, or more, of the following hazardous properties: • Toxic.

• Carcinogenic.

• Toxic for reproduction.

• Mutagenic.

Service users on cytotoxic or cytostatic medication must have this documented in their care plan and appropriate training and personal protective equipment should be provided for staff (see MMSOP34 - Standard Operating Procedure for the Management of Pharmaceutical Waste for list of cytotoxic and cytostatic medication).

Personal Protective Equipment (PPE) • • • •

Always wear appropriate PPE (e.g., gloves [preferably nitrile] and a disposable apron) when administering cytotoxic/cytostatic medication and should be appropriate for its intended use.

Always ensure personal protective equipment is disposed of safely to prevent potential harm to others. Discuss with your clinical waste contractor or community pharmacy.

Staff must be trained in the use of PPE, and it must be adequately maintained and stored.

Service users and care staff should wash hands thoroughly following administration of cytotoxic/cytostatic medication.

Administration of cytotoxic/cytostatic medication • • • • • • • • • •

The prescription should clearly state the dose and frequency for administration.

Phrases such as ‘as directed’ must not be used and the prescriber should be consulted to change the directions.

Cytotoxic/cytostatic medication should never be dispensed in a compliance aid or a monitored dosage system (MDS).

Reduce handling to prevent unnecessary exposure to cytotoxic/cytostatic medication when administering to service user.

Tablets should not be handled directly. Staff should wear gloves.

Oral doses should be dispensed into a medicine pot. Doses can be unwrapped at the time of administration by the care staff.

Only remove cytotoxic/cytostatic medication from its container when in front of the service user.

Tablets should be swallowed whole with a glass of water whilst sitting or standing.

NEVER crush, chew or break tablets.

Transfer medication from bottle/foil to a single use medicine pot/spoon or oral syringe.

Medicine pots, spoons and syringes should be disposed of after each administration in the cytotoxic/cytostatic designated waste receptacle. Wear appropriate PPE for this process.

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Safe Disposal of cytotoxic/cytostatic medication Waste contaminated with cytotoxic/cytostatic substances should be disposed of in suitable authorised facilities, normally incineration facilities (see MMSOP34 - Standard Operating Procedure for the Management of Pharmaceutical Waste).

21.

Oxygen

Oxygen will be prescribed for each individual service user if the prescriber considers it necessary. Advice on storage and administration may be obtained from the supplier but the following guidelines should also be followed: • Cylinders must be stored under cover and not subject to extreme temperatures.

• The storage area must be clean, dry, well-ventilated and away from highly flammable liquids, combustibles and sources of heat and ignition.

• Cylinders must be stored upright and secured by way of a chain to the wall.

• Empty cylinders must be stored separately and easily distinguished from full cylinders.

• The statutory warning notices must be displayed in any room/area where oxygen is used or stored.

• Oxygen therapy must only be discontinued, or the flow rate altered by the direction of the prescriber.

• Equipment must be handled by trained staff or under the supervision of trained staff only.

• Regular stock checks will be carried out with particular attention paid to expiry dates.

• Care staff should only support with oxygen administration if they have been trained and assessed as competent to do so.

A risk assessment must be completed by the supplier, a copy of this should be retained and kept for records. Staff must ensure they understand the risk assessment and when to notify the supplier if risk changes. Staff can also liaise with medicines management colleagues if they have any questions. Refer to MMPOL14 Medical Gas Policy

22.

•

• •

Medication Incidents and Errors

If a member of care staff is aware of having made a mistake in assisting with medicines, or notices that an error has been made they should immediately notify their manager (by phone). If they are unable to contact the manager, the care staff should not delay seeking medical advice.

Staff must be supported and able to raise concerns directly and in a timely manner.

Refer to the Whistleblowing Policy and Procedure at Provide Care Solutions (Freedom to Speak Up (whistleblowing) Policy).

The manager should ensure the following action is taken: • Seek advice from the GP or appropriate health professional immediately.

• Enter the details of the error in the care record, and on the MAR chart, both of which are kept in the service user’s home.

• Make a note of any changes or deterioration in the service user’s health or behaviour.

• Ensure the error is fed into the care provider’s incident reporting system, through Datix /Access and is investigated in order to share learning and prevent recurrence.

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• • •

The manager will undertake an initial investigation of the incident on the same day, ensuring immediate remedial actions have been put into place which may include informing the GP. The manager will undertake a full comprehensive investigation within 14 days and conclude the report on Datix.

If the error involves a controlled drug this will also need to be reported to the Provide Controlled Drug Accountable Officer (CDAO) Nisha Desai 07580 911601 Nisha.desai@nhs.net

Root causes and lessons learnt will be cascaded to all staff and any changes to policy or procedures will be acted upon immediately to ensure the safety of all service users and staff.

Duty of candour The duty of candour requires registered providers and registered managers to act in an open and transparent way with service users receiving care or treatment from them (see QSPOL03 Being Open and Duty of Candour Policy).

All staff are required to follow QSPOL01 – Incident Reporting & Management Policy

23.

Medication handling when service users go out

Records must be kept on the ‘Medication Dispensing - Day Trip and Social Leave’ form of all medicines entering/leaving the home with service users.

The most suitable option for service users taking their medication with them when they go out must be selected after consideration of the risks of the individual situation. Risks include: • how long the service user is out for • who they are accompanied by and their competence.

• the nature of the medication they are taking.

• how much notice has been given of the intention to go out.

The following options must be considered: • missing the dose out altogether (after confirmation with the GP).

• giving the dose early or late (after confirmation with the GP).

• giving the original dispensed medicine to the relative/carer/service user (if competent to administer) • obtaining a separate labelled supply for ‘leave’ (advance warning required to obtain a prescription and get it dispensed) A record of the option agreed must be made on the MAR.

Medication handling for hospital admissions Records must be kept of all medicines coming in and going out of the home with service users for the purposes of hospital admissions. A copy of this is included in the Transfer and Discharge from Hospital Pack. A copy must be retained in the service user’s notes.

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24.

Medication Reconciliation

Staff must carry out a medication reconciliation process when a new service user moves in and brings their own medication with them and also when they return after a period of time away, e.g. hospital. This is to gather information about the service user’s medication and to ensure that the medication they are bringing with them is in date and is as stated on the pharmacy label.

Tablets in foil strips stored within boxes - check the medication name, batch number and expiry date on each foil strip must be identical to the information on the box.

Bottles of liquid medicine - unopened/sealed bottles only may be used; any bottles which have been opened or the seal broken must be disposed of unless there is a date of opening or disposal date noted on the bottle.

Containers of loose tablets - unopened/sealed containers only may be used; any containers which have been opened or the seal broken must be disposed of (see Provide MMPOL33 Medicines Reconciliation Policy).

25.

Resources Available to Support Care Staff

Health and social care staff should be able to access reliable and up-to-date information about medicines. Resources may include the patient information leaflet supplied with the medicine and the following websites: • Medicines and Healthcare products Regulatory Agency.

• NHS choices.

• NICE Evidence.

• British National Formulary (BNF).

• Pharmacist advice and support.

• Patient Information Leaflet.

• Clinical Knowledge Summaries.

• Electronic Medicines Compendium.

26.

Risk Management/Monitoring/Audit

Risks will be managed, monitored and mitigated by the following mechanisms: • Provides medicines team will continue to support Provide Groups on medicines management training, updates and competencies.

• The content of this policy will be approved by Provides Medicines Governance & Safety Group • Regular monitoring of incidents reported by Provide Group staff on the Datix /access incident reporting system.

• Feedback of learning from incident reports to relevant Provide Group staff and to independent providers of such care.

• As schedule of audit will be developed and reviewed annually to support safe, high-quality care.

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Appendix 1: Levels of Assistance with Medicines (Based on Professional Advice: The administration of medicines in domiciliary care published by the Care Quality Commission (CQC): Quality, Performance and Methods Directorate: January 2009).

Level 1: General Support, also called Prompting / Assisting with Medicine •

General support needs should be identified at the care assessment stage and specified in the care plan.

•

General support is given when the service user takes responsibility for their own medication. In these circumstances the care staff will always be working under the direction of the service user receiving the care.

•

The support given may include some or all of the following: • requesting repeat prescriptions from the GP • collecting medicines from the community pharmacy/dispensing GP surgery • disposing of unwanted medicines safely by return to the supplying pharmacy/dispensing GP practice (when requested by the service user) • reminding or prompting by the care staff to a service user to take their medicines. (A persistent need for reminders may indicate that a service user does not have the ability to take responsibility for their own medicines and should prompt review of the care plan) • manipulation of a container of prescribed medicine under the direction of the patient, for example opening a bottle of liquid medication.

Service users can retain independence by using compliance aids including monitored dosage systems. These may be considered if packs and bottles are difficult to open or if the service user has difficulty remembering whether he or she has taken medicines and other options are not appropriate. Other options include, but are not limited to: • • • • • •

Reminder charts or administration record Large labels Colour coding / pictograms Non-childproof tops Removing tablets/capsules from blisters into a bottle Medication review (to make the medicines regime simpler, provision of appropriate formulations or remove medicines no longer required)

•

The monitored dosage system (MDS) will normally be filled and labelled by the community pharmacist or dispensing GP. The service user may qualify for a free service from a community pharmacist if they meet criteria under the Equality Act 2010..

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Level 2: Administering Medication • • •

•

• •

The need for medication to be administered by care staff should be identified at the care assessment stage, specified and recorded in the care plan. Ongoing records will also be required in the care record.

The care assessment or the Medicines Assessment may identify that the service user is unable to take responsibility for their medicines. This may be due to impaired cognitive awareness but can also result from a physical disability.

The service user must agree to have the care staff administer medication and consent should be documented in the care plan. If a service user is unable to communicate informed consent, Provide’s Consent Policy and the provisions of the Mental Capacity Act must be followed.

Administration of medication (Level 2 support) may include some or all of the following: • When the care staff selects and prepares prescribed medicines for immediate administration. When the care staff selects and measures a dose of prescribed liquid medication.

• When the care staff applies a medicated cream/ointment/patch; inserts drop to ear, nose or eye; and administers inhaled medication.

A managed system must be in place to ensure that only competent and confident staff are assigned to service users who require help with their medicines.

Care staff must be able to identify each individual medication against the MAR chart.

Level 3: Administering Medication by Specialised Techniques •

• • •

In exceptional circumstances and following an assessment by a healthcare professional, a domiciliary care staff may be asked to administer medication by a specialist technique including: • Non- insulin diabetic medication (injectables).

• Insulin by injection.

• Buccal midazolam for epileptic seizure.

• Assistance with oxygen.

• Administration via an enteral feeding tube e.g. PEG. If the task is to be delegated to an individual care staff for an individual service user, the healthcare professional must train the care staff and be satisfied they are competent to carry out the task.

A risk assessment must be completed to identify and mitigate any risk of error in administration.

The SOPs must include that care staff can refuse to assist with the administration of medication by specialist techniques if they do not feel confident or competent to do so.

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Appendix 2: SOP for Use of the Medicines Administration Record (MAR) Chart Care staff who provide support with medicines to service-users should: • • • •

Only carry out this service if you have received training and been assessed as competent by your manager.

Only use a MAR chart that has had the medication details added by a responsible professional (this may be a pharmacist, registered manager or other responsible person of a social care service, a doctor or nurse) NEVER tamper with the instructions on the MAR chart Care staff working at this level will need to: • check the instructions give all the information and do not say “As directed”.

• check the dosage timings are clearly indicated on the chart.

• ensure clear instructions are included for “when required” doses (e.g., maximum number of doses per day and minimum time between doses, and under what circumstances the medication should be given) • At the end of each month, start a new MAR chart.

• Contact the responsible professional who has provided the chart with any queries regarding the instructions on the chart.

• Contact your manager if you have any concerns or problems.

• Add your name and initials to the “Who administers Medication?” section of the chart page 2.

• Check the date on the front of the chart to make sure that it’s in current use, and that it is the only MAR chart in use, unless there are two which should be numbered.

• Complete the “Medication count” section for any supplies received during the month.

Administer the medicines shown on the MAR chart, using the steps below for EACH MEDICINE, ONE BY ONE: 1. Check the record and ask the service user to make sure the medication has not already been given.

2. Wash your hands.

3. Select the medication required and confirm that it is still current by checking the date on the dispensing label.

4. Check that the name of the service-user, the name of the medicine and the instructions on the bottle/box are the same as those on the MAR chart - IF NOT DO NOT GIVE IT. 5. Check whether the medicine is to be given by mouth or by another route (e.g., to be inhaled, applied to the skin etc).

6. If oral, ensure the service user is standing or sitting as upright as possible, and has a glass of water available.

7. Give the medicine to the service-user with a drink of water.

8. If applying a cream or medicated patch, or administering a hazardous medicine (see risk assessment) for a service user, ensure you are wearing appropriate disposable gloves.

9. Enter your initials clearly and appropriate code on the correct date and time to show you have seen the service-user take the medicine or complete electronic task.

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10. If the dose is variable (e.g., one or two tablets to be taken) record the actual amount given and initial.

11. If the medication is NOT GIVEN enter the appropriate code in the correct box /electronic task and enter the reason in the service-user’s care record. Report this to your manager immediately or seek immediate medical advice.

12. If the medicine is left out (this must be specified in the care plan) for the service user to take themselves at a later time, enter a large UW in the box, and record in the care record.

ALWAYS contact your manager should a new medicine appear that is not accounted for anywhere on the chart.

Always bring any concerns to the notice of your manager.

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Appendix 3: Guidance on the Expiry Dates and Storage of Medicines in Care Homes and Supported Living There is much confusion about the issue of expiry dates within care homes. This has led to issues with patient safety and the wastage of medication. National guidance is not available for all products and this guidance will improve patient safety; reduce wastage and support sensible medicine use in care homes.

As part of good medicines management, service user should receive medication that is “in date”.

• To ensure that the active ingredients are fully effective.

• To reduce the risk of contamination.

• To ensure that it is safe to use.

The expiry date or use by date for any medication is calculated by the manufacturer and it is a legal requirement for it to be printed on the original container from the manufacturer.

What does 'expiry date' mean?

The expiry date means that the medicine should not be used after the end of the month.

For example, if the expiry date is January 2022, the medicine shouldn’t be given after January 31, 2022.

What does 'use by date' mean?

If the medicine has a use by or use before date instead of an expiry date, this means that you shouldn't take the medicine after the end of the previous month.

For example, if the use by date is January 2022, the medicine shouldn’t be given after December 31, 2021.

Medicines may go “out of date” because of: • Inefficient prescribing or re-ordering systems.

• Stockpiling.

• Receiving excessive quantities.

• Poor stock rotation and not checking expiry dates (ensure the community pharmacist provides a batch number and expiry date on any medicines decanted from bulk containers).

When required (PRN) medicines: NICE Guideline SC1 Managing medicines in care homes states: • Care homes staff (registered nurses and social care staff working in care homes) should ensure that “when required” medicines are kept in their original packaging.

• Can be carried forward each month following the expiry guidance as given overleaf.

• Should be stock rotated to ensure that the oldest medicines are used first.

• Must NOT be returned and re-ordered each month but carried over to the next month and recorded on the MAR chart to complete the audit trail.

Key points for basic storage conditions • Keep all medication in the original container in which they were dispensed and ensure it is only used for the service user for whom it was prescribed.

• Keep medicines in their original outer packaging, to protect from sunlight.

• All medicines should be stored in a cool (below 25°C) dry place unless refrigeration is required (between 2°C and 8°C) – temperatures should be recorded daily, and a documented process should be in place should the temperature fall out of range.

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• • • •

The expiry date of the product can change once opened.

Record the date opened and the calculated expiry on the medicine package/label.

Store as recommended by the manufacturer and be vigilant with product expiry dates.

Seek advice from the community pharmacist if medicines are found to have been stored outside their intended conditions or if their dispensing labels become illegible e.g., on creams etc. Do not discard on this basis alone.

Before ordering each month, a care home nominated member of staff (or their deputy) should: • Check the current stock levels of medication, especially items which are not supplied in individually packed multi-compartment aids or stored on the medicines trolley.

• Some service users may need a medication review (GP or pharmacist will check patient’s medicines to revise items / quantities prescribed in the future).

• Report excessive quantities returned regularly – ask the GP or pharmacist to review if it still needed, or to prescribe smaller quantities.

Formulation Tablets and capsules in original packs Tablets and capsules packed in MDS Tablets and capsules – loose, put into a bottle by the pharmacy Liquids (internal) Liquids (external) Creams/ Ointments in tubes or a pump dispenser

Creams/ ointments (pots/ jars) Suppositories/ pessaries/ rectal tubes / patches Inhalers Ear / nose drops and sprays Eye drops/ointments

Inhalers Injections (except insulin) Insulin

Recommended expiry date Manufacturer recommendation As stated by Pharmacy 6 months from dispensing date or manufacturer’s recommendation when shorter. Pharmacy to highlight any shorted dated stock.

6 months from date of opening or manufacturer’s recommendation where shorter 6 months from date of opening or manufacturer’s recommendation where shorter 6 months from date of opening or manufacturer's recommendation where shorter. For unopened creams follow the manufacturer's recommendation 3 months from date of opening or manufacturer's recommendation where shorter Manufacturer’s recommendation Manufacturer’s recommendation Discard 3 months after opening unless manufacturer advises otherwise 1 month after opening or manufacturer’s recommendation where longer (e.g., Hylo-Fresh® eye drops = 6 months and VitA-POS® eye ointment = 6 months) Manufacturer’s recommendation Manufacturer’s recommendation Insulin should be stored in the fridge and can be kept unopened until the expiry date. Once opened it can be stored outside of the fridge for up to 28 days.

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Appendix 4: Patient Controlled Drug Collection Form from Community Pharmacy

Patient Controlled Drug Collection Form from Community Pharmacy

Patient Information Name: Address:

Controlled Drug Collected- details available on prescription.

Drug Name

Strength

Form

Quantity

Details of Staff Collecting Name: Signature:

Pharmacy Details Pharmacy Name: Pharmacy Address: I confirm above medication has been collected by Care Staff named above: Pharmacist Name: Pharmacist Signature: Date:

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Appendix 5: Patient Returns Form

Patient Controlled Drug Returns Form Patient Information Name: Address: Consent For Return Obtained: Y / N Name and Signature of Person Giving Consent: Reason for Return: Medicines Information Drug Name Strength

Form

Quantity

Details of Staff Returning Name: Signature: Returned Date: Returned to (please circle):

Pharmacy

Witness: Sign

Pharmacy Driver Date:

Details of Staff accepting Return Pharmacy/Driver Name: Pharmacy Address: I confirm receipt of the above listed drugs and quantities for destruction.

Driver/Pharmacist Name: Driver/Pharmacist Signature: Date

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Appendix 6: List of Controlled Drugs and their Schedules This is not exhaustive but aims to cover the most common CDs encountered in clinical practice. Brand names are not listed, except where no generic name exists, or is not commonly used.

Schedule 1 CDs includes drugs not used medicinally such as hallucinogenic drusgs (e.g.

LSD, raw cannabis. A Home Office licence is required for their production, possession and supply Controlled Drug

Schedule

Controlled Drug

Schedule

Amobarbital (Sodium Amtal) Anabolic Steroids Aspirin and papaveretum

3

Gabapentin

3

4 (Part II) 5

2 5

Benzodiazepines (except temazepam, midazolam & Flunitrazepam) Buprenorphine Chlordiazepoxide Cocaine Co-codamol Codeine, but if oral dose form and max strength per dose unit <100mg

4 (Part 1)

Hydromorphone Kaolin & morphine mixture and tablets Ketamine

3 4 (Part 1) 2 5 2

Lisdexamfetamine Meprobamate Methadone Methylphenidate Midazolam

2 3 2 2 3

Morphine* Oxycodone Pentazocine Pethidine Phenobarbitone Phentermine

2 2 3 2 3 3

Pholcodine (nonparenteral) Pregabalin Quinalbarbital Sativex® (see note above) Tramadol Zopiclone

5

Dipipanone

5 5 5 5 2 2 See codeine 2

Equagesic Fentanyl Flunitrazepam

3 2 3

Co-Dydramol Co-phenotrope (Lomotil®) Co-proxamol Dexamphetamine Diamorphine Dihydrocodeine

Zaleplon

2

3 2 1 3 4 part 1 controlled drugs (CD Benz POM) 4 part 1 controlled drugs (CD Benz POM)

*Lower strengths of morphine mixtures are Schedule 5 CDs, but local acute trusts may manage them as if they were Schedule 2, i.e., full safe custody and record keeping. Please contact your supplying acute trust pharmacy department, or the Provide Medicines Management Team for further details.

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EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’ Name of project/policy/strategy (hereafter referred to as “initiative”):

Managing Medicines in Provide Care Hokes and Domiciliary Care Services

Provide a brief summary (bullet points) of the aims of the initiative and main activities: To provide guidance and information on the safe us and management of medicines in Social Care Signpost staff to enable them to seek support if required Provide guidance on safe use of MARS charts and drug errors Project/Policy Manager: Nisha Desai

Date: April 2024

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e., on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e., have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how?

Or is it clear at this stage that it will be equality “neutral”? i.e., will have no particular effect on any group.

All staff and service users I Provide Care Solutions and Domiciliary Care services

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why?

Or is it clear at this stage that it will be equality “neutral”?

No

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

No

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Guidelines: Things to consider • • •

• • •

•

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e., young and old,), race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e., have no particular effect on the group/community.

Where a negative (i.e., adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g., by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so, can this be justified? - e.g., are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

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EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2: (To be used where the ‘screening phase has identified a substantial problem/concern) This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities?

Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

n/a

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

n/a

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g., men and women? n/a

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation. n/a

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

n/a

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Via Audit and Pharmacy team visits Page 41 of 42

Guidelines: Things to consider • • •

• •

An initiative may have a positive impact on some sectors of the community but out others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information: Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.efa.org.uk – Employers forum on age © MDA 2007 EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’

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