MMSOP68 Management of Meds in PCH Fern Lodge V4

Suite of Standard Operating Procedures (SOPs) for the Management of Medicines in Care Homes (Fern Lodge)

Version: V4

Ratified by: Medicines Governance and Safety Group

Date ratified: 18/12/2025

Job Title of author: Director Quality, Pharmacy and AHP

Reviewed by Committee or Expert Group Medicines Governance and Safety Group

Related procedural documents MMPOL37 Managing Medicines in Provide Groups Care homes

Review date: 18.12.2028

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

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

1. Introduction

Care Homes provide accommodation and care for people who need substantial help and support with living and often this includes medicines. Where possible service users are supported to be as independent as possible, however support maybe needed with both their prescribed medication and medicines bought over the counter from the pharmacy. Care Quality Commission (CQC) provides guidance on the standards expected for processes to meet safety, good care and any legal requirements of medicines. These Standard Operating Procedures (SOPs) support the safe use of medicines in a residential care setting using CQC and the National Institute for Health and Care Excellence (NICE).

2. Scope

The SOP suite applies to the processes for managing medicines within the residential care setting and suite is for all staff who have responsibility for the safe and effective administration of medicines to all service users.

3. Purpose

The purpose of this SOP suite is to support consistent and safe processes in relation to medicines at the residential setting within Provide Community.

4. Monitoring and Audit

Risks will be managed, monitored and mitigated by the following mechanisms:

• Provide’s medicines team will continue to support Provide Groups on medicines management training, updates and competencies.

• The content of these SOPs will be approved by Provide’s 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, highquality care.

5. Review

These SOPs will be reviewed every 3 years and/or following a change in national or local guidance or legislation or following analysis of a local incident or near-miss.

6. Training Requirements

All staff responsible for prompting, assistance or administration of medicines must complete training and be assessed as competent to do so on an annual basis.

7. Definitions

Expiry Date

As Required (PRN Medication)

Variable Dose

Personal Protective Equipment (PPE)

MDT

Covert Administration

PEG

Routes of Medication Administration

• The expiry date is the point in time when a pharmaceutical product is no longer within an acceptable condition to be considered effective.

• The medication reaches the end of its ‘shelf life.’

• Medicines that are taken 'as needed' are known as 'PRN' medicines.

• PRN is a Latin term that stands for 'pro re nata,' which means 'as the thing is needed.'

• Medications are sometimes prescribed to allow variable dose amounts to be administered, up to a maximum total dose in a dose interval. This is specified in the field’s 'dose' and 'frequency' for PRN medications in the MAR.

• Equipment that will protect the user against health or safety risks at work. It can include items such as gloves, eye protection, disposable aprons.

• Multi-disciplinary team

• This is the term used when medications are hidden and given without the consent of the Service User

• Percutaneous Endoscopic Gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation)

This is a list of the different routes that medication can be administered:

• Buccal: Held inside the cheek

• Enteral: Delivered directly into the stomach or intestine (with a PEG tube or Jejunostomy Tube)

• Inhalable: Breathed in through a tube or mask

• Nasal: Given into the nose by spray or pump

• Ophthalmic: Given into the eye by drops, gel, or ointment

• Oral: Swallowed by mouth as a tablet, capsule, lozenge, or liquid

• Otic: Given by drops into the ear

• Sublingual: Held under the tongue

• Topical: Applied to the skin

• Transdermal: Given through a patch placed on the skin

Rights of Medication

The 6 Rights of Medication are:

• Right Service user

• Right Medicine

• Right Route

• Right Dose

• Right Time

• Right to Refuse

Body Map

• A body map is a blank diagram of a person, showing their front and back, used to document information for future reference. They can be used for recording where creams, lotions, etc. should be applied, injection sites, transdermal patch sites, lacerations, bruising or pressure ulcers.

Time-Sensitive Medication

Patient Information Leaflets (PIL)

Controlled Drugs (CDs)

• A medicine that needs to be given or taken at a specific time, where a delay in receiving the dose or omission of the dose may lead to serious Service User harm, for example, insulin injections for diabetes or specific medicines for Parkinson's disease.

• Every medicine pack includes a Patient Information Leaflet (PIL), which provides information on using the medicine safely.

• PILs are based on the Summaries of Product Characteristics (SPCs) which are a description of a medicinal product's properties and the conditions attached to its use.

• Some prescription medicines are controlled under the Misuse of Drugs legislation (and subsequent amendments). These medicines are called controlled medicines or Controlled Drugs

• These are prescribed medicines which are usually used to treat severe pain, induce anesthesia or treat drug dependence and have additional safety precautions and requirements. (Royal Pharmaceutical Society)

• Examples include morphine, gabapentin and pregabalin.

Schedule 2 and Schedule 3 Controlled Drugs

MAR

• The Misuse of Drugs Regulations 2001 (and subsequent amendments) define the classes of person who are authorised to supply and possess Controlled Drugs while acting in their professional capacities and lay down the conditions under which these activities may be carried out.

• In the regulations, drugs are divided into five schedules (this includes Schedule 2 and 3) each specifying the requirements governing such activities as import, export, production, supply, possession, prescribing, and record keeping which apply to them.

• A MAR (Medication Administration Record) is a working document used to record the administration of medicines. Ideally, they should be produced by the pharmacy on a monthly basis at the time of dispensing and delivered with the medication.

8. MMSOP01: Self Administration

Service users are able to take responsibility for their own medication if they wish, within a risk management framework. It is important that, as long as the service user has been risk assessed and deemed able, self-administration is encouraged and supported by the home. This can help to maintain independence. Self-administration may be particularly suitable for those service user prescribed inhalers, insulin, creams or new service users who are confident with their medication.

Assessment

Ability of a service user to self-administer will be established after a risk assessment is completed (Appendix 1). The assessment will ascertain how the service user managed their medications when in their own home.

Service users or carers should be given the information about this and provided with support in reading it if necessary. The service user or carer must be asked to give their verbal consent for assessment. If problems are identified, how they might be resolved, and any actions taken must be documented. This may require referral to a community pharmacist or pharmacy technician who can, for example, provide bold or large type labels or other administration aids.

Authorised staff must give appropriate information to service user/carers/parents about their medication. This should include:

• Name of the drug

• Why they are taking it.

• Dose

• Frequency of administration

• Any special instructions

• Commonest side effects and what to do if they occur.

• Duration of the course or treatment

• Pertinent religious or dietary information

In addition, service users should be provided with a full explanation of how the selfadministration of medicines process works:

• The supply/source of medicines that will be used (service user’s own or other)

• How to obtain further supplies

• How the medicines will be stored

• Key keeping arrangements (to protect others)

• What to do if a dose is missed or forgotten, or if too many/few are taken

• What to do if they wish to ‘opt out’ of the scheme

• What to do about ‘PRN’ medications

• Service users concerns.

(Appendix 1 Self Administration Assessment Form)

9. MMSOP02: Medication Assessment

A full medicines assessment must be completed for each new service user. This can be completed on paper using Appendix 2 or electronically. This will be completed by the (care assessor) Registered Manager or Senior members of staff.

The assessment will cover the following:

• Past medical history

• Allergies

• Medicines currently being taken.

• How the service user takes their medicines

• What if any level of support the service user requires to manage their medicines

In exceptional circumstances this medicines assessment can be delegated to another member of staff. However, this member of staff must have the appropriate skills to complete the assessment and make a judgement on any support needed.

This should be carried out at the time specified in the care plan or sooner if there are changes in the service user’s circumstances, such as:

• Changes to their medicine’s regimen.

• A concern is raised.

• A hospital admission.

(Appendix 2 Medication Assessment Form)

10. MMSOP03: Ordering of Medications

Ordering a Prescription - General Principles

• 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 (see MMSOP 01 and 02)

• The service user must give consent for the prescription to be ordered (Appendix 3).

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

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.

Process for Ordering Medication

• Check current stock of service user’s regular medication.

• Check if a new supply of medications prescribed as required (PRN) are needed. Only order if needed.

• Put a prescription request of what medications are required into the GP surgery/Pharmacy via the appropriate method (some practices accept paper, online and email request) 10-14 days before the medication is due to run out, most practices require 3-5 days to turn around prescriptions and additional time is required for dispensing of the prescription by the community pharmacy).

• The current nominated GP is Mount chambers and ordering is done via SystmOnline Login (tpp-uk.com)

• The Registered Manager, the Deputy Manager and the team leader have access log in and passwords for this and are able to access for all service users that require support with their medication.

• Once logged onto the website medication can be ordered by clicking on the service users requiring medication ordering (each individual has their own). Click on ‘request medication’ on the bottom of the left had page. Once the list of medication is open, please use the tick boxes on the left-hand side to request the medication needed and press continue.

• Check the service users details below in the request:

• Name

• D.O. B

• Address

• Medication name, strength, form, and quantity required

• Keep a record of what was ordered.

• If there is a medication that requires ordering that is not on the list after pressing continue there is a note box which can be completed to request medication that isn’t on the list, full details will need to be supplied of the medication. Please also Email repeats.mchambers@nhs.net to ensure that the surgery complete this request.

• To order the next service users medication click on ‘other patient record’ and order their medication following the steps above.

Please forward all ordering forms to the nominated pharmacy (Borno, Great Square Braintree) email great.square@borno-chemist.com so these can be checked.

• When the prescription is ready, check what has been ordered against what has been received and flag any discrepancies immediately.

(Appendix 3 Consent for care provider to order medicines)

11. MMSOP04: Collection of Prescriptions/Medication

Collecting a Prescription - General principles

• Prescriptions are normally sent electronically to a nominated pharmacy but there may be occasions where it needs to be collected, this should only be collected as part of the agreed Care Plan.

• The Service user must give consent for the prescription to be collected.

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

Collecting a Prescription from a GP Surgery

• Staff can collect a repeat prescription for the service user from the GP surgery if the service user has given consent to the surgery for you to collect the prescription. You will usually be asked to confirm the name and address of the person you are collecting the prescription for

• The GP surgery is not legally required to check your identity, but some surgeries may ask to see proof of identity to prevent the wrong prescription being given out.

Collecting medication from the Pharmacy

• Medication is generally delivered to services from the nominated pharmacy, there may be circumstances where medication may need to be collected from the pharmacy.

• Staff can take a prescription form to the pharmacy to collect the service user’s medication for them. The service user must complete part 1 on the back of the prescription form (FP10) and you, as the service user’s representative, must complete parts 2 and 3.

• If the service user has topay a prescription charge, the correct amountmust be entered in part 2. If the service user is exempt, you may be asked to show evidence of the exemption, e.g. an exemption card.

• The pharmacy staff will then check the back of the FP10 form to make sure that it is signed, that the appropriate category is ticked if the service user is exempt from charges and confirm that you are acting on the service user's behalf and with their permission.

• Only the service user’s Prescription Prepayment Certificate (PPC) can be used for prescriptions that have been issued to them – if you have one, it cannot be used.

• If a false claim of exemption is made, a penalty charge may be issued, and the service user could be prosecuted, routine checks are made.

• If you are collecting a CD (also known as 'controlled medication') for the service user, the pharmacist may request proof of identity. CDs include Morphine, Fentanyl, Oxycodone and Buprenorphine. These medicines are prone to being misused, so have stricter legal controls on their supply.

• The dispensing pharmacist will use their professional judgment to assess each situation on a case-by-case basis, i.e., who is collecting the prescription and why.

• If there are any concerns about collecting the medication, contact the registered manager or senior staff.

• Record in the service user's notes when medication is collected.

• Ensure that medication is returned promptly to the service user and stored correctly.

• A new MAR chart must be transcribed for the medication. Ensure that any changes in medication are communicated to the registered manager or senior staff so that the MAR chart can be amended, if necessary.

• Open the medication boxes and count the contents to ensure the correct number of tablets/capsules are in the box. This is not necessary if the box is sealed. Also check that the medication boxes and the MAR charts match with all the correct details

• Write on the outside of the box stating the date they were checked and initial this.

• Where specific request has been made to the pharmacy, e.g. a request to halve a tablet for a service user, and this has not been done by the pharmacy – please return these tablets and ask the pharmacist to cut them in half – do not cut these at the care home.

• Once medications have been received, they must be booked in and checked by two members of staff.

Obtaining Medication in an Emergency

If a service user urgently needs medicine, you must contact their GP immediately to arrange a prescription.

You can also ring 111 or visit NHS 111 online to request an emergency supply of medicine

12.MMSOP05: Storage of Medicines

General Principles

• Medicines must be stored where they are readily accessible to all carers and service users who are able to administer independently.

• 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.

• Keep all medication in the original container in which it was dispensed.

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

• All medicines must be stored in a cool (below 25°C), dry place unless refrigeration is required (between 2°C and 8°C).

• The expiry date of products can change once opened (refer to MMPOL37)

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

• Be vigilant with product expiry dates.

• Store as recommended by the manufacturer.

• Note and act on any specific storage instruction, e.g., 'store in the fridge'.

• Rotate stock so that the earliest expiry is at the front and therefore going to be used first, i.e., ‘first in, first out’.

• Check expiry dates of medication stock and this includes any blister packs.

• Medication is to remain in the container in which it was received.

• Medication is stored in the locked cupboard in service user’s room or in a lockable cupboard in the care home medication storage area.

• One key must be given to the service user (if appropriate) and a spare key (which is labelled) must be kept securely by the registered manager. 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.

As Required Medication (PRN)

Be aware of the expiry date of PRNs, especially if they are not used frequently. It is good practice to date and initial on opening all PRN medication for audit trail purposes.

Storage of Medication Other Than Tablets or Capsules

• Dates of opening, or starting to use the medication, will be recorded on such items that have a short shelf life once opened, e.g., liquids, creams, eye drops.

• Medications beyond their expiry date will not be used and must be disposed of appropriately.

• Where medication is stored in a fridge, the fridge must be checked to ensure that it is in working order and temperatures recorded daily on the Daily Temperature/Cleaning Chart

Storage of Oxygen

• If a service user is prescribed oxygen, the registered manager must discuss storage with the company who supplies the oxygen. Their advice must be documented and followed.

• Oxygen cylinders must be stored safely, under cover and not subject to extreme temperatures. This will be in a dry, clean, well-ventilated area away from highly flammable liquids, combustibles and sources of heat and ignition.

• Cylinders must be handled with care, never knocked violently or allowed to fall over. They must be switched off when not in use. Cylinders will only be moved with a trolley specifically designed for the cylinder size unless it is a small portable cylinder.

• Oxygen concentrators must be stored upright and plugged directly into the mains socket. Adequate ventilation must be provided around the concentrator. They must always be switched off when not in use.

• In the case of fire, it is the responsibility of staff to inform the fire brigade that oxygen cylinders are present and where they are located. When evacuating a service user from the care home, cylinders left in the premises will be switched off, where it is safe to do so, as part of the evacuation process.

• Care must be taken where service users use dressings, bandages, creams or ointments that contain liquid paraffin as this is highly flammable.

13.MMSOP06: Administration of

Medication Administration Principles

Medicines

• Service users will be fully involved in the management and administration of their medication.

• Service users will be fully involved in decisions regarding their individual medication and its purpose, and staff will have shared with them, in a method which promotes their understanding, the medication Patient Information Leaflet (PIL) provided by the dispensing pharmacist.

• Before medication is administered to any service user, consent must be obtained.

• Where a service user is unable to give valid consent due to mental incapacity, best interest meetings will take place and, where it is agreed that it is in the best interest of the service user, including their medical interests, that medication is administered, then formal authorisation for medication administration will be obtained and evidenced in the service user’s Care Plan and medication records

• Medication administration must promote service user independence, choice, privacy, and dignity.

• Medication administration must take account of the service users' cultural and religious values and beliefs.

• Medication must not be used as a form of restraint to sedate service users for the convenience of the staff. This is abuse and a breach of Human Rights.

• Medication must only be administered to the service user who has been prescribed that medication.

• All care staff, including those who are not directly concerned with the administration of medicines, will be trained in the understanding of medications, the main types of medication in use, their administrative procedures, and how to look for and report possible adverse reactions, including changes which may require review of the service user’s medication prescription.

• Only staff who have undertaken the medication training, and who have been assessed as competent, will be involved in the administration of the medication.

• Records of care staff who are trained and assessed as competent to administer medicines will be held by the registered manager

• Covert medication must not be given to a service user who has the capacity to give their consent or refusal medical treatment.

• Care staff must not administer medication from family filled dosette boxes in line with best practice guidance.

Types of Medication Support

The registered manager or senior staff are responsible for assessing and agreeing on the type of medication support required and ensuring that the appropriate record-keeping and training needs are met. The service user’s Care Plan will require review as needs change. Involvement with the wider multi-disciplinary team may be required to ensure that the service user's independence, needs and expectations are met.

Procedure

• Care staff will only provide support with medication administration if it is agreed in the Care Plan.

• Wash and thoroughly dry hands and assemble any equipment that may be required, e.g., medicine spoons. Any liquid medication must be measured into a clearly graduated and marked medication pot or by using an appropriately sized oral syringe which clearly identifies individual millilitre markings.

• Always use disposable powder free gloves when administering medicines

• Check the service user's identity and allergy status - 6 Rights of Medication Administration.

• Check that the service user consents to have their medication. Where a service user lacks capacity, check that the best interest decision is in place.

• Check the physical state of the medication, including the expiry date and labelling and check that it has been suitably stored. If the medication label and MAR do not appear to match, then advice must be sought from the Registered Manager/senior staff before administration.

• Check the required dose and any special instructions on the dispensing label (e.g., not to be given with milk or antacids or to be taken with food, etc.) and take appropriate action.

• Contact the registered manager or senior care staff if there are concerns that the dose has already been given by another care staff. Do not give the dose until it is confirmed that it is safe to do so.

• Ensure that the service user is either in a standing position or sitting upright. Staff must not attempt to assist withmedication for service users who are in a prone position. Medicines must be swallowed with plenty of water, e.g., 100-150ml of water or at least half a glass.

• Check that the medication has been taken.

• Record the appropriate option on the MAR chart that the medicine has been given or that it has been offered and declined. If the service user declines to take a medicine, the care staff must consider waiting a short while before offering it again. Care staff will ask about other factors that may cause a service user to decline their medicine, such as being or not being in pain or discomfort.

• If the service user still declines, the care staff will complete the MAR chart with the correct code as well as the daily record log. The care staff will report this to the Registered Manager immediately. The Manager will need to seek clinical advice from the GP or Pharmacist if the Service user declines their medication. Out-of-hours advice may be sought from 111.

• Return the medicines to the safe storage place as identified on the risk assessment.

• Ensure that the MAR chart/care records are stored securely and appropriately. Remove gloves and aprons and wash hands.

Administration Do's and Don'ts

• Do only administer medication if you have been trained and assessed as competent to do so.

• Do make sure that medication is given at the time agreed on the Care Plan and MAR chart. The timing of medication administration can be crucial and adherence to medication prescription instructions must be followed. This must be clearly indicated in the medication Care Plan and in the MAR chart

• Do make sure that medicines are given only to the service user for whom they are prescribed, following the prescription instructions.

• Do give medicines from the container in which they are supplied. Medication doses will not be put out in advance (potted up) as this can lead to errors and accidents.

• Do check where the service user's medication is stored before starting medication administration. It may be in the refrigerator or separate jars or tubs.

• Do always check the medication and MAR chart, do not rely on memory.

• Do always ask the service user if they want to take their medication before removing it from the pack. If they decline to take the medication try again a little later. The refusal must be documented, and the GP or Pharmacist telephoned for advice.

• If the tablets or capsules are in a pharmacy-filled monitored dosage system, do open the appropriate section and empty the tablets/capsules into a medicine pot and hand it directly to the service user

• Do transfer the medication from the bottle or pack into a medication pot and give this directly to the service user.

• Do make sure that any variable dose or PRN medication is given as indicated in the Care Plan and what was given is documented.

• Do seek advice if a service user cannot swallow their medication. Advice must be obtained from a healthcare professional and alternative liquid medication may be able to be prescribed. Medication will not be crushed or split without prior approval from the prescriber as this may affect the way medicines work and can be potentially harmful to the service user.

• Do report any concerns and log any incidents, errors or omissions as soon as you become aware.

• Do mark any medication that has a short shelf life after opening with the date after which it will not be used on the container.

• Do hand over all information regarding changes to medications administration to relevant staff and ensure that they have received and understand the message.

• Do not take medication from its original container and give it to another member of staff to give to the service user, as the person checking the right dose for the right person must also witness the person taking the medication and must be sure that the medication has been taken properly by the service user.

• Do not handle medication but transfer to the medication pot in a non-handling, clean method

• Do not use part-used medication that has been dispensed to one service user, and is no longer required, for any other service user.

Splitting Medication

• When it is necessary to split a tablet to provide the required prescribed dose, the supplying pharmacy will be asked to supply the medication as split tablets in an appropriate container.

Crushing Medication

• Crushing medication may alter the way in which a medicine is absorbed and its effect on the body.

• Crushing medication invalidates a product license so crushing medication must always be authorised by the prescriber.

• Where it has been agreed with the prescriber that crushing medication is in the service user's best interest, advice from a pharmacist may be sought if required. The prescriber can give authority to crush mediation.

• Other alternatives such as the availability of liquids or other forms of medicines will be discussed.

• Written authorisation from the prescriber for each medicine that needs to be crushed, and the period the authorisation applies, must be recorded and retained with the service user's medication records.

• Where staff are required to give crushed medication via specialised technique, such as via a PEG tube, they will only administer when trained and assessed as competent to do so.

Time Sensitive Medication

• The times of administering medication are essential and there are often set times for some medication.

• It is important to know if the medication is required to be taken a specified number of hours apart, as taking some medications too closely together can result in toxicity.

• It is important to document clearly that medications have been given on the MAR chart.

• No double doses must ever be given, e.g., if a service user declines one dose do not give two doses the next time around. This will be recorded on the MAR chart using the correct reason code.

• Staff responsible for administration of medication will be made aware of any timesensitive medication.

• The Registered Manager will ensure that prescribers, supplying pharmacists and dispensing doctors, provide clear written directions on the prescription and dispensing label on how each prescribed medicine will be taken or given, including for time-sensitive medicines. Information must include:

• What the medicine is for

• What dose must be taken?

• What time the dose must be taken, as agreed with the service user

Running balance/End of day Check

• Medicines count must be completed for all service users after each administration.

• Count all medicines including PRN and over the counter where applicable.

• Ensure the physical amount medication matches the MAR chart.

• If any medicines are not correct/there are any concerns, contact Registered Manager /or senior staff in charge for advice on what actions to take.

14.MMSOP07: Other Routes of Medicines Administration

• Care staff will only provide support with medication administration if it is agreed in the Care Plan.

• Wash and thoroughly dry hands and assemble any equipment that may be required,

• Always use disposable powder free gloves when administering medicines

• Check the service user's identity and allergy status - 6 Rights of Medication Administration.

• Check that the service user consents to have their medication. Where a service user lacks capacity, check that the best interest decision is in place.

• Check the physical state of the medication, including the expiry date and labelling and check that it has been suitably stored. If the medication label and MAR chart do not appear to match, then advice must be sought from the Registered Manager before administration.

• Check the required dose and any special instructions on the dispensing label.

• Care staff will ensure that the Infection Control Policy and Procedure is followed.

• All staff will ensure that the dignity and privacy of a service user is maintained when administering medication, including via routes other than oral. Irrespective of whether a service user has the capacity to give informed consent, the service user must be informed of what actions are taking place and they must be treated with compassion at all times.

• Care Plans will detail how the medication is to be administered, including sites for topical application, injections or transdermal patches.

• Where it applies, individual service user risk assessments will be completed for any risks associated with routes of administration.

• Body maps will be used for each topical medication required. Body maps will also be used for detailing transdermal patch sites.

• If a service user requires non-insulin diabetic injections, the injection sites must be rotated, and a body map and record made in the service user's notes.

• Where transdermal patches are required, the patches must be disposed of as per the Patient information Leaflet. Patches that contain a controlled drug will be disposed of as per the MMPOL37

15.MMSOP08: Disposal of

General Disposal Procedures

Medicines

Medicines no longer required by the service user will be disposed of by returning to the dispensing pharmacy.

• At no time may one service user's prescribed medication be used for any other person.

• No medicine will be thrown in the bin or down a sink or toilet. Any sharp objects (e.g., needles) or other clinical waste will be disposed of into designated bags/containers.

• No out-of-date medicines or discontinued medicines are to be kept. Out-of-date medicines for disposal must be kept separate from medicines in use.

Care staff will only return medicines for disposal to the dispensing pharmacy if:

• The administration of medication is required as part of the Care Plan.

• They have completed Medication returned to Pharmacy Form (Appendix 4) as a record of disposal.

Disposal applies to:

• Medication that has been discontinued.

• Medication remaining due to a service user's treatment having been changed or discontinued.

• Dispensed doses that have been refused.

• Medication that is past the expiry date.

• Medication remaining after a service user has died.

PRN Medication

When required, “PRN” medications in bottles or packs will be checked for expiry dates and sent back to the community pharmacy or dispensing doctor when out of date. Any outof-date items will be re-ordered from the individual service user's GP if still required.

Controlled Drugs (CDs)

CDs will be returned to the Pharmacist or dispensing Doctor at the earliest opportunity for safe disposal. When CDs are returned for disposal, a record of the return will be made using a Medication Returned to Pharmacy Form (Appendix 4) and the Pharmacist or dispensing Doctor MUST provide a signature to note their return.

Disposal of Patches

Used patches will be disposed of by folding back and sticking the adhesive sides together and then disposing of them safely as directed in the Patient Information Leaflet.

Sharps Disposal

Where a service user’s medication support generates ‘sharps’ (needles, syringes, lancets for finger pricking for testing blood) then these must be disposed of in a designated ‘sharps bin’ supplied through the GP or Community Nursing Team. Care staff will only be providing support with this if it has been agreed as part of the Care Plan, a risk assessment is in place and specific additional training has been undertaken.

Disposal of Liquid Medication

In the event of a care staff measuring a dose of oral liquid medication and the service user then refusing to take it, the following actions will be taken:

• Do not return the dose to the medicine bottle.

• Place it in a suitable container, if available.

• Mark it as waste and name the medicine.

• If it will not be going to the pharmacy immediately, ensure that it is stored securely and removed as soon as possible

The Care staff must make an entry in the Communication and the Visit Log indicating that the dose has been disposed of. The Care staff must also inform the Registered Manager.

Deceased Service Users

Medication belonging to recently deceased service must be kept until any relevant investigations are completed if applicable. Police or courts require them as evidence as part of any investigation into the death of the service user.

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.

Appendix 4: Medication returned to pharmacy form

16.MMSOP09: Record of Medicines Administration

Medication and Care Plan Information

A service user's Care Plan will include:

• The support needed includes details of specific requirements.

• Up-to-date MAR chart(s) detailing current medication where support with administration is required. A list of ‘current medication at date’ must be stored in the service user's record.

• Contact details of the Prescriber, Community Pharmacist and other appropriate healthcare professionals

Medication Assessments

• A full medication assessment must be completed for each service user. This must include both prescribed medication and any over the counter (OTC) medication.

• For service users who need no medication support, the Care Plan must indicate that they are self-managed, and any risks associated with this must be identified and recorded.

• The medication assessment must indicate the agreed support that the care staff will deliver.

• The medication assessment must be reviewed annually, after an accident, incident or near miss, or if there are any changes to a service user’s circumstances (including changes to medication), care or health needs.

Medication Administration Record (MAR) Information

The Medication Administration Record (MAR) for an individual service user will include:

• Their name

• Their address

• Their date of birth

• Any other available person-specific identifiers such as the NHS number

• Any known drug allergies (if none, then this fact must also be recorded)

• The name, formulation and strength of the medicine

• How the medicine is taken or used (route of administration)

• The dose, time to be taken or used, and any special instructions, e.g., with or after food.

• Any stop date for a medicine

• Reference to any separate specialised administration MAR if one is in use, e.g., warfarin, when required medication.

MAR Recording Procedure

Record what you do when you do it. As medicines are administered, if verbal reminders or physical assistance is provided it must be recorded immediately and logged by the person providing the medication support.

• Record any medications not taken, providing a reason.

• Medication with variable doses must be clearly recorded on the MAR chart with the actual dose given.

• Where there are any changes to the care agreed in the Care Plan, the care staff must report to the Registered Manager. This includes if a service user refuses medication.

MAR Times

• Where specific times are not detailed on the pre-printed MAR but printed as 'morning', 'lunch, 'tea-time', 'bedtime' (or suitable abbreviations), the manager will check with each individual service user what this means and obtain guidance from the GP if required.

• For example:

• Morning means 8:30 to 10:00

• Lunch means 12:30 to 14:00

• Teatime means 18:00 to 19:30

• Bedtime means 22:00 to 23:30

• The time bands can be individualised for each service user and the information kept alongside their medication records, beside their medication storage or within their Care Plan. Care will be taken to ensure that the times between doses are sufficient.

Discontinued Items

• Ensure the service users records are updated.

Change of Dose

When a Prescriber amends the dose of a medication part-way through the MAR chart, the following procedure will be followed by staff:

• Obtain written confirmation of the dose change.

• Immediately after the last administration entry, record ‘stopped on date and time, dose change’ and sign entry.

• Mark a single diagonal line through the medication details box to indicate clearly that the medication has been stopped.

• Take care to ensure that there is an adequate quantity of medication available if the dose has been increased.

Change of Times or Frequency of Administration

• Update the records and/or system with the new information.

• If the original prescription says, 'one three times a day' and the service user wants to go to bed earlier than they used to, then you can bring the dose forward to fit in with their new routine. The GP will not necessarily have to be involved in this decision if the original prescription does not have a specific time on it.

• There must not be numerous entries at 22:00 recorded as 'not taken' because the person was asleep. The time of administration must be brought forward.

• If the frequency is being changed, then ask the Prescriber to confirm this in writing or follow the organisation’s procedure for verbal instructions.

• Care must be taken that doses are not administered too close together and guidance will be sought from the prescriber.

Change to 'When Required' or 'for Regular Administration'

• Ask the Prescriber to confirm this in writing.

Instructions on Dispensing Labels

If the instruction on the MAR chart is different from the instruction on the dispensing label, then the information on the MAR chart must explain why. This might be because the dose was originally to “take two in the morning” and it has now been changed to “take one in the morning”. As the dose was reduced, there is sufficient supply for the person so there is no need to get another prescription dispensed. If there is no clear explanation, advice must be sought from the registered manager or senior member of staff.

Reviewing MARs

• The Registered Manager will ensure that 10% of MAR charts are audited each month and any themes or trends are discussed at the quality meetings.

MAR Omissions

• If a care staff realises at any time that they an omitted medication /dose on the service users MARS, they must notify the manager immediately.

• An investigation will be started, and consideration must be given depending on the medication and the impact on the service user's health and wellbeing, as to whether a Safeguarding Notification needs to be raised.

• Any trends in errors or omissions will be tracked to identify any administration and recording issues.

Time-Sensitive Medication

Prescribers, supplying pharmacists and dispensing doctors must provide clear written directions on the prescription and dispensing label as to how each prescribed medicine will be taken or given.

For time-sensitive medicines this includes:

• What the medicine is for

• What dose must be taken?

• What time the dose must be taken, as agreed with the Service User

Registered managers or senior staff will record any additional information to help manage time-sensitive and when required medication in the Care Plan.

Patient Information Leaflets

The supplying pharmacist or dispensing doctor must supply a Patient Information Leaflet for each medicine supplied. Care staff will ensure that an up-to-date Patient Information Leaflet for each prescribed medicine is kept and made available to service user

17.MMSOP10: Controlled Drugs

Controlled Drugs (CDs) are those defined by the current Misuse of Drugs Regulations 2001, which classify CDs into 5 schedules according to the level of control required.

Care homes must ensure CDs comply with the Misuse of Drugs Regulations 2001and associated regulations when storing CDs.

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

Storage

• Care homes must ensure CDs comply with the Misuse of Drugs Regulations 2001 and associated regulations when storing CDs.

• The CD safe or cabinet must comply with the requirements specified in the Safe Custody Regulations (British Standards BS2881).

• The CD cupboard should only be used for the storage of CDs. No other items such as money should be placed there.

• If the CD requires safe custody and it has been provided in a monitored dosage system (MDS) the MDS should be stored in a CD safe or cabinet

• Access to the CD cabinet should be restricted. The keys should be kept under the control of a designated person and there should be a clear audit trail of the holders of the key.

• All Schedule 2 andthoseSchedule 3 CDs that aresubject to safe custody requirements (i.e., Midazolam, Temazepam, Buprenorphine, and Phenobarbital) must be kept in a locked receptacle, which is constructed and maintained so as to prevent unauthorised access to CDs. Note: Gabapentin and Pregabalin are also exempt from safe custody requirements.

Recording

• All care homes should keep a record of service users own CDs in addition to the records maintained on MAR charts. This should be a controlled drug register.

• The register should be a bound book with numbered pages and a separatepage should be used for each service user’s medicines and should also have a column for recording running balances.

• The register should be used to record the receipt, administration and disposal of CDs held in the care home.

• There must not be any cancellations, obliterations or alterations. Corrections must be made by a signed and dated entry in the margin or at the bottom of the page.

• On receipt of a CD the date quantity and source should be entered into the register and initialled by appropriately trained receiving healthcare professional or authorised member of staff with a second person as witness. The correct balance should be verified each time.

• Registers should be kept for a minimum of TWO years after the date of the last entry.

Identifying a Controlled Drug

Commonly seen products are listed below but this list is not exhaustive:

• Oral drugs include MST Continus®, Sevredol®, Zomorph®, MXL®.

• Patches include: BuTrans®, Durogesic DTrans®.

• Oramorph® Oral Solution (10mg/5ml) must be recorded as a CD because of the risks involved in its use.

Administration

• Designated and appropriately trained staff only, must administer CDs. A second, appropriately trained designated member of staff must witness the administration.

Administration should follow the same guidelines that are observed when administering any other medication however the following steps should also be taken:

• The service user’s name, date, time and dose given, should be recorded in the CD register after carefully checking the administration sheet.

• Before administering the medicine, the stock balance should be checked, and the dose measured and checked with a competent witness.

Oral Liquid Controlled Drugs

• These must be measured and administered using an oral/enteral syringe. These are available from the pharmacist.

• Where possible, the top of the oral liquid bottle will have a press-in bottle adaptor of the correct size inserted to ensure that the dose can be measured accurately.

• Liquid oral CDs must always have the dose clearly indicated only as the volume in milliliters on the MAR chart.

• Pharmacy medication labels will always show the dose in this way e.g., TWO 5ml spoonful (a 5ml oral syringe is equivalent to a 5ml spoon for measuring and the syringe must be used as there is less chance of spillage).

PRN Controlled Drugs

For ‘when required’ dosing there must be specific instructions for the care staff on the dose, frequency and maximum number of daily doses.

Disposal of Controlled Drugs

All controlled drugs no longer needed must be returned to the pharmacy as soon as possible. Staff should complete the medication returned to pharmacy form (Appendix 4) CDs should be put on their own page in the controlled drugs returns book. When CDs are returned to the pharmacy staff will need to complete the CD register and will need to document how many have been returned and to which pharmacy they have been returned to. This will need to be signed and dated by two appropriately trained staff.

Errors, Omissions or Near Misses

• If an error occurs when a CD is given, as with any other medicine, this may have serious consequences for the service user.

• The Care staff will first contact the service user's GP for advice.

• If theGP is unavailable or it is out-of-hours, 111 must be contacted, or 999 if considered appropriate.

• The Care staff must also speak to the registered manager or senior staff in charge.

• Follow the Accident and Incident Reporting Procedure.

• If there have been serious consequences for the service user as a result of an error or omission, then a regulatory notification will be submitted to the Care Quality Commission and Provide Controlled Drug Accountable Officer (CDAO) Nisha Desai 07580 911601 Nisha.desai@nhs.net

Controlled Drugs and the Death of a Service User

If a Service User dies suddenly or unexpectedly, medication including any CDs will not be removed from the care home without prior permission from the coroner as they may be required by the coroner.

Discrepancies

Care homes are required to follow the below procedure when dealing with discrepancies, incidents and errors related to CDs. Any concerns should be reported immediately to the registered manager.

If a discrepancy is identified between what is expected and the supply received, then the following guidance is provided:

• Enter the stock into the CD register indicating what was obtained, not what was requested.

• Contact the suppling pharmacy as soon as possible to investigate and resolve the discrepancy.

• Store the CD separately in the CD cabinet awaiting collection.

• Arrange for the supplier to pick up the incorrect CD.

• When the stock is picked up, obtain a signed receipt from the person taking it away, and make an entry into the supplied section of the CD register.

• Datix discrepancy received from suppling pharmacy within 48 hours.

If the CD received is deemed ‘unfit’ for use the following guidance is provided:

• Enter the medication received into the appropriate section of the CD register.

• Store the CD in the CD cabinet in a sealed bag marked ‘Damaged Stock’ until it is taken away.

• Inform the pharmacy that the stock received is ‘unfit’ for use, explaining the reason and arrange for the pharmacy to pick up the stock.

• When the stock is taken away, obtain a signed receipt from the person taking it away, and an entry must be made into the supplied section of the CD register.

• A Datix is raised to log the wrong supply or stock discrepancy.

If a discrepancy is identified between calculated stock figures (running balances) and actual stock the following guidance is provided:

• Check back through the entries for that medicine and ensure that there has not been a recording or numerical error.

• Check the MAR chart and also any records of disposed medicines.

• If the discrepancy can be identified, record the outcome and make any corrections to the CD register with a signed and dated entry (this a retrospective entry) in the margin or at the bottom of the relevant page making reference any supporting documentation that was used to resolve the discrepancy There must be no cancellation, obliteration or alteration of any entry in the CD register.

• This needs to be signed and dated by an appropriate witness.

• If the discrepancy cannot be explained or rectified, then contact Provide’s CD Accountable Officer within 24 hours.

• If the discrepancy cannot be explained or rectified and the CD is a Schedule 2 CD then the police will need to be informed

• Datix will need to be raised within 48 hours.

Appendix 4: Medication returned to pharmacy form

18.MMSOP11: Homely Remedies

Homely remedies are products that can be purchased from a pharmacy or supermarket over the counter for the relief of minor, self-limiting ailment without the need for a prescription. Homely remedies are to be made available in care homes to allow access to medicines that would commonly be available in any household.

Before any homely remedy is administered there must first be an agreement with the service user’s GP that they are happy that the service user is to be treated with these remedies.

This agreement should state the type of minor ailments that may be treated and the remedies that may be used. Examples of minor ailments include:

• Indigestion

• Mild pain/ fever

• Coughs

• Constipation

• Diarrhoea

• Skin conditions- although some skin conditions are considered minor ailments, since creams and ointments should not be shared between service users, they are not suitable to be used as homely remedies in the care home setting.

An agreement should be signed by the GP for each of service users under their care to ensure that the proposed remedies will not interfere with any medication they are already prescribed

An agreement should be signed by the GP for each of service users under their care to ensure that the proposed remedies will not interfere with any medication they are already prescribed

Care staff who give non-prescription medicines or other over-the-counter products (homely remedies) to service users should be named in the homely remedies process. They should sign the process to confirm they have the skills to administer the homely remedy and acknowledge that they will be accountable for their actions. 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 user’s 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

Administration should not exceed two days without medical advice being sought.

Any symptoms that do not respond to a homely remedy must be reported to the GP.

19.MMSOP12: As Required and Variable Dose Medication

PRN Medication

The term PRN (from the Latin pro re nata: for an occasion that has born/arisen) is given to a medication which is to be taken “when required” and is usually prescribed to treat short term or intermittent medical conditions and not to be taken regularly i.e. not given as a regular daily dose or offered only at specific times e.g. medication rounds. Analgesics, occasional night-time sedatives and laxatives are amongst common examples of medicines prescribed in this way.

Staff administering medication will have the appropriate training and follow the procedures set out in the relevant medication management policies and Standard Operating Procedures (SOPs). However, when administering PRN medication, the following points need to be considered:

• If PRN medicine is administered on a regular, rather than an occasional basis (best practice is no more than 3 days), a referral to the prescriber will be considered for a review of the service user’s medication. This action must be clearly recorded in the service user’s Care records

• Should the PRN medication not have the expected effects, the prescriber will be contacted. This action must be clearly recorded in the service user’s Care records

• All PRN medication that is prescribed must give details of a maximum of how much and how often a medication can be administered.

To ensure that the medication is given as intended, a specific plan for administration must be recorded in the Care Plan or a when required protocol (see Appendix 6). Information should be documented in the Care Plan on:

• The reasons for giving the ‘as required’ (PRN) medicine.

• Dose instructions, including the maximum amount to be taken in a day and minimum interval between doses (if appropriate). Where a variable dose is prescribed, the PRN protocol should include information on how a decision is made

• on the dose to administer (e.g. 1 or 2 tablets)

• What the medicine is expected to do.

• The shortest time to wait between doses if the first dose has not worked.

• Signs and symptoms to look out for and when to offer the PRN medication

• Whether the person can ask for their medicines or if they need prompting or observing for signs of need e.g. non-verbal cues. If observation charts are being used to determine need e.g. pain charts, stool charts, make reference to these in the protocol.

• Where more than one PRN medicine is available for the same condition (e.g. multiple painkillers), it should be made clear when it is appropriate to use each one.

• How long the person should expect to take the medicines.

• When to review the medicine, for example, what to do if the medicine is taken regularly or not used for a long period of time. Time periods will vary depending on the medication, resident and circumstances.

PRN medicines should remain in their original packaging.

Consideration will be given to the service user’s capacity to refuse the medication. When providing staff with information, the needs of the service user must be identified, e.g., if signs of pain are expressed in a non-verbal way.

A record will be made of evidence, on each visit, whether the service user was offered the medication and the reasons for not offering will be recorded. The medicines should be

offered in a person-centered manner. Offer the medicines to the service user when they are experiencing symptoms. Make a record of the exact time and the amount of medicine given.

The Care Plan will detail the circumstances when the medication is or is not required. Staff will be able to explain why the medication is required.

If medicines do not have the expected effects (such as effective pain relief), contact the prescriber. Keep a record of responses from prescribers about queries to medicines.

Variable Dose Medication

When variable dose medication is prescribed (for example, give ONE or TWO tablets), it is essential that the actual dose given is recorded. This will be done on the MAR chart or where considered necessary for clarity, a supplementary recording sheet could be used. Staff will ensure that a person-specific procedure is in place, similar to that used for “as required” medication, which details how the dose is to be given as advised by the prescriber. The procedure will be kept with the service user's MAR. The procedure will be reviewed at least every 6 months, or sooner if circumstances change.

Appendix 6: PRN PROTOCOL

20.MMSOP13: Warfarin Good Practice Guidance

• Warfarin is an anticoagulant medication that requires close monitoring.

• Warfarin tablets must be taken at the same time each day with a full glass of water.

• If a dose is missed, a note must be made on the blood test form and the MAR chart Continue the next day with the normal dose, do not give an extra dose to ‘catch up’.

• Warfarin will be administered from original packs and will not be included in Monitored Dosage Systems, e.g., nomad or dosette boxes.

• It is important that the care staff administering medicines are familiar with the different colours of the various strengths of Warfarin tablets, as different colours (strengths) of tablets may be required to make up a dose.

• Always double check the most recent International Normalised Ratio (INR) report when giving a dose. It is essential that dosages are not given from old INR reports.

• If you have not received the record within 3 days, contact the anticoagulation service or GP.

• If there are any concerns that the INR result for a service user is out of date, contact the anticoagulation service or GP for advice.

Identifying Concerns

Like all medicines, anticoagulants have side effects. The most common side effect of anticoagulants is bleeding. You must contact the service user's GP immediately if they experience any of the following:

• Nose bleeds that last for more than 10 minutes

• Blood in vomit or sputum

• Passing blood in urine or faeces

• Passing black coloured faeces

• Severe or spontaneous bruising

• Unusual headaches

• Suffered a fall.

• For women, heavy or increased bleeding during your period or any other vaginal bleeding.

Warfarin Tablets

Warfarin is available in four different strengths of tablets, 500 micrograms, 1mg, 3mg and 5mg. Care must be taken to ensure the correct strength of tablet is chosen.

• 500 micrograms (0.5mg): white tablet

• 1mg: brown tablet

• 3mg: blue tablet

• 5mg: pink tablet.

Warfarin and Other Medication

• Many medicines can interact with anticoagulants. If, during a course of anticoagulants, a service user is also starting or stopping another medication, the prescriber may advise that they must have a blood test within 5 to 7 days of starting or stopping the new medication. This is to make sure that the INR remains within the desired range.

• Oral anticoagulants interact with a wide variety of other medicines (for example, commonly prescribed antibiotics and painkillers), in most cases leading to an increased anticoagulant (blood thinning) effect. Before using over-the-counter medicines, including alternative remedies, care staff must get advice from a healthcare care professional. Where service users are self-managing, they will also be advised to seek advice.

Warfarin and Diet

• It is important for service users to eat a well-balanced diet. Any major changes in diet may affect how a service user's body responds to anticoagulant medication.

• Foods rich in vitamin K may affect an INR result. Such foods include green leafy vegetables, chickpeas, liver, egg yolks, cereals containing wheat bran and oats, mature cheese, the seaweed found in sushi, blue cheese, avocado and olive oil. These foods are important in a diet but eating them in large amounts may affect the INR result. It is important to take the same amount of these foods on a regular basis. It is the change in the vitamin K intake that affects an INR result.

• A moderate intake of alcohol will not affect anticoagulation but changing the amount a Service User drinks or drinking large quantities is dangerous.

• Drinking cranberry juice and possibly grapefruit juice can also affect INR levels and so must be avoided in large quantities.

• If the service user suddenly changes their diet and it is thought that this will interfere with their warfarin, their GP should be notified with their consent, also advise that the service user tell the anticoagulation clinic at their next appointment.

INR Blood Results

• For most service users the anticoagulation service will usually contact the GP with details of a service user's INR test result, new dose and the date of the next blood test. The service user may also be notified directly.

• Service users will continue to take their previous dose of Warfarin until they receive this information in written form from the GP.

• The new dose may differ on different days of the week, and this will be clearly stated in the letter/email.

• The anticoagulation service may need to telephone the care provider if the dose needs to be changed urgently.

Good Practice - Service User commencing treatment

When a service user is initiated on Warfarin, this must be recorded in the Care Plan stating the:

• Location where anticoagulant therapy is managed (i.e. at the anticoagulation clinic at the hospital, GP practice or community pharmacy)

• Date the Warfarin commenced.

• Medical condition it is prescribed to treat, e.g., atrial fibrillation.

• INR target and range

• Date of the next INR test – contact prescriber if it is not stated.

• Current dose, in milligrams (not number of tablets)

• Time of day the dose is to be given.

• Date to stop treatment, if applicable.

• Dosing instructions up to the next INR test.

Good Practice - Maintaining the Service User's Warfarin treatment record

• Periodically the service user will need to have a blood test to determine the INR reading.

• It must be established at the onset where the test is performed.

• The test may result in a change in the Warfarin dose.

• The frequency of the blood test is dictated by the INR reading and is specific to each service user.

• The date of the next INR test will be decided at the time of dosing and must be documented in the Care Plan.

• The information received from the clinician managing the anticoagulation will include the date of the last INR test, the dose of Warfarin, and the date of the next INR test.

• When a service user is discharged from hospital, they may be prescribed Warfarin doses for a few days only. The Registered Manager must contact the ward that discharged the service user if:

• The dosing instructions run out before the next INR test.

• There is no date for the next INR test.

Good Practice - Receiving changes to the Warfarin dose

Where the dose of the Warfarin is changed due to the INR reading, or changes to other medication the service user may be taking, then:

• Observe the service user’s anticoagulant record for the current dose of Warfarin.

• Any changes to the dose received by telephone must be verified by another suitably qualified staff member and a written copy or email requested. Written confirmation will ensure that there is documentation of the change in dose from the clinician managing the Service User’s therapy.

• When new dosing instructions have been received, the MAR chart must be updated with the new dose and date of the next INR test. Two signatures are required to check the daily dose regime with the clinician’s instruction.

Good Practice - Administering the Medication

Due to the variable dose of Warfarin, it is unsuitable to be placed in a monitored dosage system, e.g., Dosette Box. Therefore, it will be supplied by the community pharmacy in an original pack.

• Check the service user’s current dosage instructions (in anticoagulant record book or equivalent)

• Check if there are different strengths prescribed in order for the service user to receive the prescribed dose.

• Check if the service user is prescribed a variable dose (different doses to be given on different days, e.g., 2mg one day alternating with 3mg the next).

• When variable doses are prescribed, document on the MAR chart, and in the Care record the combination to be used in order for the service user to receive the correct dose, e.g., 2mg dose = 2 x 1mg tablets, 3mg dose = 1 x 3mg tablet.

• Check the service user's name, the drug name, the strength of the tablets and the expiry date on the original pack supplied by the community pharmacy.

• Warfarin will be taken at the same time each day, generally around 6pm. This is to allow any urgent change to the Warfarin dose to be made following a blood test earlier that day.

• It is very important that Warfarin is given daily as prescribed. Missing doses of Warfarin may have serious consequences. Please ensure that all staff are aware of this. It is not acceptable to omit a dose of Warfarin due to the service user sleeping.

• If a dose is missed at the prescribed time, it can still be administered on the same day, i.e., before midnight. If staff realise the previous day’s dose was missed, a double dose must not be taken. The missed dose must be documented and reported to the clinician managing the service user’s Warfarin as soon as possible. Subsequent doses will be taken at the usual time.

• You may wish to consider routine auditing of MAR charts for Warfarin administration.

Good Practice Guidance - Signing the MAR following administration

• The MAR chart must be completed immediately after care staff have administered the Warfarin to the service user.

• If there is a combination of tablets to be taken, then this must be entered on the MAR chart to inform others of how the dose was given.

Good Practice Guidance - Service User carrying Anticoagulant Alert Card and having a yellow book

• Service users taking Warfarin must have a copy of the ‘NHS Oral Anticoagulant Therapy – Important information for patients’ (yellow book). The alert card is to be carried with the service user when leaving the care home, e.g., day excursions.

21.MMSOP14: Covert Medication

It is recognised that there may be certain, exceptional circumstances in which covert administration may be considered to prevent a service user from missing out on essential treatment. In such circumstances and in the absence of mental capacity, the following considerations may apply:

• The best interests of the service user must be considered at all times.

• Medication must be considered essential for the service user's health and wellbeing or for the safety of others.

• The decision to administer medication covertly must not be considered routine and will be a contingency measure.

• Any decision to do so must be reached after assessing the care needs of the service user individually.

Establish the Service User's Ability to give Informed Consent

This will be done via a discussion directly with the service user about their medication. If the service user consents, then covert medication will not be used. If the service user consents but there is doubt about their capacity, then the principles of the Mental Capacity Act (MCA) must be followed, and medication will not be given covertly. It must be noted that no one, not even a family member, can consent on behalf of someone else when the person concerned is an adult with capacity

Establish the Reason why the Service User does not Wish to Take the Medication

Consideration will be given as to whether this reflects a concern about medication, whether an advance directive regarding refusal of medication exists or whether there is a religious or cultural belief. All are valid reasons for declining medication and must be respected. The service users’ reasons for refusal will be recorded in their records.

Ensure that Alternatives have been Explored

Alternative preparations must be offered, and flexibility (where possible) given. Research shows that medication acceptance is improved when the service user has been involved in the decision-making process and has been enabled to have some control over what is prescribed.

Establish that the Medication is Essential

If consideration is being given to covert administration of medication, then the medication that the service user is declining must be deemed to be essential for their health and wellbeing or for the safety of themselves or others, and this must be documented in the service user's care record.

Establish that the Person Lacks the Mental Capacity to Make the Decision Themselves

The principles of the MCA must be followed. A capacity assessment will take place directly with the service user where a conversation will be had about their medication. It must be determined that the service user is unable to:

• Understand information relevant to the decision, e.g., the risks associated with not taking it.

• Retain this information (if only briefly)

• Weigh up the information/risks involved.

• Communicate their decision.

As detailed in the MCA (2005), all reasonable efforts must be made to help the service user understand. It must be recognised that capacity may fluctuate during the day and so the best time of day will be chosen. In some cases, several attempts may be required. A record must be made of methods used to help overcome any communication issues including the use of an interpreter.

If the service user successfully passes these four tests, then they will be assumed to possess the mental capacity to make the decision themselves, even if their decision appears unwise. In these circumstances, the decision must be respected, and covert medication cannot be given.

Discussion About Best Interests

Having established that the service user lacks capacity, a decision about whether covert medication is in their best interest must, therefore, be had in an open and inclusive way, ensuring that all factors are considered.

The views of people involved in the service user's care will be sought, as it is important that the decision to administer covert medication is not an isolated one. Members of the multidisciplinary team, the service user's family (unless it is clear that the service user would not wish for them to be involved), people closest to them, and (if applicable) their GP, the Registered Manager, Advocate, or Independent Mental Capacity Advocate (IMCA) will all be invited to express a view.

It is crucial that a decision is reached which is based on what the service user would have wanted, not necessarily what is best for their physical or mental health. If an advance directive exists, the service user's wishes stated within it must be respected as they are legally binding.

Where consensus cannot be reached, or there is concern about the restriction of liberty, a DoLS (Deprivation of Liberty Safeguard) application and/or a second opinion may be useful.

Involvement of the Pharmacist

Advice must be sought from the pharmacist when mixing any medication with food or drink. This is to ensure that the medications that the service user takes are safe to be given in this way and that recommendations can be made about the use of alternative formulations or medications as necessary.

Any changes to the service user’s medication after a plan for covert medication is put in place will also be discussed with the dispensing pharmacy.

Documentation

In order to be transparent and to provide a clear audit trail, all service users receiving covert medication will have a Care Plan which contains information about why it has been decided that the person will receive their medication covertly.

A clear record of which medicines are being administered covertly and when, must also be maintained. The Care Plan must also include:

• Actions taken to give medication in the normal manner.

• How medication will be administered covertly

• Specialist input to show suitability of the method chosen (for example, crushed or mixed with certain food or drinks)

• Whether the medicine is unpalatable

• Adverse effects (actual or perceived)

• Swallowing difficulties

• Ethical, religious or personal beliefs about treatment

• What to do if the service user refuses food or drinks

Review

Ongoing attempts to encourage compliance are essential. As far as possible, a reason for refusal must be sought and documented within an appropriate Care Plan. Once taken, the decision to administer covert medication must be reviewed in respect of each service user on a regular basis, ideally weekly

General Principles of Covert Medication

Where covert medication is used, the following principles will be seen as good practice:

• Last resort - Covert medication must only be used when all other options have been tried.

• Time limited - It must be used for as short a time as possible.

• Regularly reviewed - The necessity of a covert medication plan will be regularly reviewed.

• Transparent - The decision-making process must be easy to follow and clearly documented.

• Inclusive - The decision must be a team one and will not be taken by one person in isolation. People closest to the service user will be involved in the decision.

• Best interests - All decisions will be made in the service user’s best interests, having undertaken a holistic assessment of the impact of covert medication on the service user

22.MMSOP15: 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):atubepassedthroughthenosedirectlyintothejejunum(small intestine).

Care staff should be aware of the risks associated with administration of medicines via enteral feeding tube. Medicines prescribed for administration via the enteral route should be in a suitable formulation e.g. liquids or soluble tablets. If a medicine is not available in a liquid or soluble form, it may be necessary to crush a tablet or open a capsule. Always refer to a pharmacist for guidance on suitable formulations and suitability of crushing tablets or opening capsules. A very limited number of medicines are licensed for administration via enteral feeding tube and most administration of medicines via this route falls outside the product license for that medicine, as does crushing tablets and opening capsules not specifically designed for this purpose. However, this may be the only option for administration of a particular drug.

Care staff should follow instructions about timing of medication and feed meticulously as some medication may interact with feed and require specific gaps between feed and medication.

All service user who requires administration of medicines via an enteral feeding tube should have had an additional risk assessment completed by the registered manager (see Appendix 7) and should give explicit consent for this to be delegated to care staff (see Appendix 8). Care staff will still need to consent the service user as normal as part of their routine day to day care and administration.

Flushing

Flushes are required:

Before and after each medication administration.

Before and after feeding.

Daily if the enteral device not currently in use.

During continuous feeds the tube should be flushed every 4-6 hours

A pulsating action (‘Push/pause technique’) should be practiced when flushing to promote turbulence within the tube. This ensures adequate flushing of the device and will help to prevent any blockages of enteral device and promote patency of the tube.

Administration of medication via an enteral feeding tube will be classed as specialised 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 workers provided: they agree this with the Registered Manager; the healthcare professional personally provides the required extra training; and is satisfied that the care workers are competent; 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. (see Appendix 9 for record of practical assessment).

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.

Appendix 7: Risk Assessment for Administration of Medication vi an Enteral Feeding Tube by Care staff Non-Regulated Staff

Appendix 8: Agreement Form to Consent to Administration of Medication via an Enteral Feeding tube.

Appendix 9: Record of Practical Assessment by the Registered Healthcare Professional acting as Assessor.

23.MMSOP16: Medication Away from Care Home

Process for management of medicines when service user stays at a location other than the care home.

Staff must record clearly who will be responsible for managing medication for service users whilst away from the care home.

Normally service users will be given dispensed containers of medicines when going away, e.g., on holiday. However, there may be occasions when an additional supply of medicines is organised for that period.

Appropriate entries on the service user's MAR chart must indicate the absence of the service user and the details of the medicines the service user has taken.

If a service user is likely to be out of the care home for one or more of the medication administration times, the service user must be given the correct medication names with clear written instructions stipulating the medication dose and time(s) to be taken. These medications must be entered on the MAR chart as given to the service user, but not administered by the staff.

• Medication must be in dispensed boxes/containers with pharmacy label.

• Medicines sign out/in record (Appendix 10) must be completed for all medicines that are leaving the care home address.

• The quantity must be counted (where possible) and details of medicines and quantity must be recorded on the form.

• When the service user returns to the care home the medications must be checked and counted back into the home.

• Staff must check the correct/expected quantity of medicines have been returned.

• Any discrepancies must be reported to the Registered Manager.

• Medicines sign out/in record must be completed for all medicines being returned (Appendix 10).

When there is a concern regarding a risk if all the medication being taken with the service user, a ‘Risk Assessment for Management of Medicines for Service User Staying at an Alternative Address’ form must be completed. (Appendix 11)

Any medication surplus to that being taken by the service user t must be removed before they leave the care home and returned promptly on their return to the original medicines cabinet.

The details of this management of medicines must be stated in the service user’s care plan.

Information staff should share

When a service user is away from their usual setting, it is important that staff give the following information to the service user or their carers:

• The names of the medicines the service user is taking with them.

• Clear directions and advice on how, when, and how much of each medicine the service user should take.

• The time of the last dose taken and next due dose of each medicine

• Contact details for any queries such as the care home, the supplying pharmacy, or the GP surgery.

Holidays booked with a holiday company

Where a service user has been booked on a holiday with a holiday company there may be a request for the service user to have blister packs, they may be a charge for this from the pharmacy.

If so, requests to the GP and pharmacy need to be made several weeks in advance to ensure these are suitable for the service user’s medication and can be provided in the time frame required.

Medication on Permanent Transfer

• On permanent transfer to another care provider, a copy of the current assessment, most recent review and the current MAR chart must be transferred together with the service user.

• Record the transfer of information in the service user’s documentation.

• Original copies of all documents relating to medications for that service user must be retained in accordance with normal practice for storage and retention.

Sharing of Information on Medications

Where service users are supported with medicine administration, staff will ensure that there is good communication either between the person caring for the service user when they are away from Provide Care Solutions, or the health professional who will have responsibility for the service user when they are away.

• Information regarding a service user's medication is confidential and must only be shared with persons or organisations who may need to temporarily administer medicines to the service user, or who are responsible for reviewing the medications, such as a hospital.

• The service user must be informed of the proposed information sharing and authorise it.

Regular appointments away from the care home for Service Users who require medication administration

• Where a service user goes out of the care home regularly, e.g., to day care, and the service user requires medication whilst away, the pharmacist and/or GP must be consulted to assess if an alternative preparation would avoid the need for the dose required whilst away, or if it could be administered at a different time.

Medication Administration Requiring Specialised Technique

• Where the Service User requires support with administration by specialised technique, there must be thorough planning to ensure that they receive their medication safely, correctly and at the right time.

• If there are additional training requirements, this will be considered, and action taken to ensure that the person responsible for administration is competent to do so.

• When required, support will be sought from other members of the multidisciplinary team.

• Additional equipment, if required, will be organised and checked and arisk assessment conducted before the journey commences.

• All discussions and actions will be documented.

• The dignity and privacy of the service user must be upheld at all times when medication administration is required outside the care home.

Appendix 10: Medicines sign out/in record

24.MMSOP17: Medication Errors and Near Misses

Reducing the Risk of Medication Errors, Near Misses and Discrepancies

A proactive approach must be taken when identifying where the risks are in relation to medication management. To achieve this, the following principles apply (this list is not exhaustive):

• Any member of staff that is responsible for medication is competent, trained and accountable for their actions as per their code of professional conduct (where applicable) or organisations policy.

• Staff feel supported and able to raise concerns directly and in a timely manner. Refer to the Whistleblowing Policy and Procedure (Freedom to Speak Up (whistleblowing) Policy).

• Systems and processes for all aspects of medication management are followed as per the suite of medication policies and procedures.

• Issues arising from partnership working are managed in a proactive and timely manner.

• Staff are aware of and adhere to notifications from national safety alerts and notices (refer to the Distribution of Safety Alert Broadcasts, Rapid Response Reporting and Safety Notices Policy and Procedures)

• Best practice is followed at all times and staff maintain their knowledge and keep updated with changes

Action to be Taken by a Member of Staff Involved in a Medication Error or Near Miss

The following actions must be taken:

• As soon as the error or near miss is identified, assess the service user's condition to establish if the service user has suffered any harm.

• If harm has occurred and the service user is unwell, call 999

• If the service user does not appear immediately unwell, report the incident to the doctor responsible for the service user's care. During out of hours contact 111

• Discuss and agree who will inform the service userthat a medication error has occurred (duty of candour)

• Document the nature of the incident in the service user's records.

• Report the incident immediately to the Registered Manager.

• If the incident involves a dispensing error, inform the relevant pharmacy immediately.

Process for Managing a Medication Error that Results in Immediate or Potentially Life-Threatening Risks

• Are there immediate/potential life-threatening risks to the service user from the incident? These can include:

• Airway obstruction

• Breathing problems

• Cardiac arrest

• Central Nervous System depression

• Severe hypotension

• Hypovolaemia

• Hypoxia

• Bleeding

• Circulatory problems, i.e., bradycardia, tachycardia

• If there are identified life threatening risks, seek emergency medical help immediately by calling 999.

• Assess and manage the patient using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach and life support measures if required.

Action to be Taken by the Registered Manager/Senior Care Staff

In the first instance:

• Assess the status of the service user if relevant and check if any harm has occurred.

• Ensure that all appropriate support has been offered to the members of staff involved in the incident.

• Confirm that the service user's GP has been informed and that the incident has been reported.

• Ensure that the incident is recorded on the service user's notes and an incident log made.

Once the service user is stable, the Registered Manager/Senior staff must:

• Ensure that a CQC notification is made if there was harm to the service user.

• Ensure that Local Authority is informed in line with local safeguarding procedures and in line with any contractual requirements (staff must refer to the Safeguarding Policy and Procedure at React Homecare and Local Authority safeguarding policies and procedures).

• Consider if Duty of Candour applies and refer to the Being Open and Duty of Candour to determine this.

• An investigation must be carried out using a Root Cause Analysis (RCA) to review what caused the incident.

• At the appropriate time, allow the member(s) of staff involved in the incident to reflect on the circumstances and identify their own learning.

• Identify if there are any training or performance issues with the member(s) of staff, and depending on the level of risk, take any necessary actions which may involve immediately suspending a member of staff from prescribing, dispensing, preparing or administering medication.

• Reflect on ensuring that there remains an open, honest and transparent culture to raise concerns, and consider reinforcing key supportive policies to staff.

Action After the Incident has Occurred – Staff

After a medication error or near miss has occurred and all of the necessary immediate actions have been taken, it is important that there will be an opportunity for the staff to discuss the incident with the registered manager as soon as possible after the incident. The purpose of the discussion is to:

• Enable the members of staff to reflect on the circumstances.

• Allow the members of staff to discuss how they feel and discuss any concerns that they may have.

• Identify if there are any training or performance issues with the members of staff.

• Determine if the medication incident is a repeat incident (check if the member of staff has made a similar medication error previously and in what timeframe)

• Dependent on the severity of the error/near miss, ensure that all appropriate support has been offered to the members of staff.

Being Open with the Service User Following a Medication Incident

It is important to be open and honest when things go wrong, therefore it is of great importance that a service user is informed if a medication error has occurred.

• The Service user must be informed at an appropriate time and an apology offered.

• If the error is of a serious nature, following the formal investigation and at the appropriate time, the service user must be offered an opportunity to discuss the outcome of the investigation and to discuss its findings. This provides an opportunity to reassure the service user that the provider is keen to always learn any lessons from medication errors and to prevent similar occurrences in the future.

• Consent will be obtained from the service user before discussing any medication errors with their family. If the service user is unable to consent due to the lack of mental capacity, the person responsible for their best interests will be informed.

• Care will be taken not to cause unnecessary alarm and information will be provided in a way that is easy to understand and enables the service user to ask questions.

• If at any time the service user or their representative is unsatisfied with the management of the medication incident, staff must signpost them to the complaints process as detailed within the Procedure for Managing Complaints and Compliments.

25.MMSOP18: Auditing and Monitoring of

Medicines Processes

The Registered Manager will ensure that there is a complete, documented audit trail from the receipt through to the administration and/or disposal of all medicines.

The Registered Manager will ensure that policies and procedures for medicines handling are accessible to staff and can evidence through audit that those policies and procedures are adhered to by staff.

There must also be evidence through audit of the service user's informed consent and that the correct procedure has been followed if a service user refuses their medication.

This system of auditing seeks to identify failures and eliminate medication errors and other medication-related risks.

Audit Cycle

The Registered Manager will be required to undertake audits of medication management. The audit schedule will be agreed in advance and the schedule cascaded to staff.

As a minimum, 10% of MAR charts will be audited, the results will be evaluated, and any themes or trends will be identified. Each service user must have at least two MAR chart audits per year.

The themes or trends will be shared with the Senior Management Team. Where changes are required to either training, procedure or policy, action will be taken to ensure continuous improvement. Where the audit highlights individual care staff concerns, these will be addressed directly with the care staff

Medication Training

Registered Manager will:

• Ensure that all staff have an annual review of their knowledge, skills and competencies relating to managing and administering medicines. Records will be retained on staff personnel files.

• Identify any other training needed for staff responsible for managing and administering medicines.

• Ensure that if a medicine-related safety incident occurs, this review may need to be more frequent to identify support, learning and development needs.

• Ensure the content of the medication training materials will be reviewed annually to ensure that it is up to date and reflects best practice.

Appendix 1: Self Administration Assessment

Service Users Consent form

• I agree to participate in the self-administration scheme.

• I have received a full explanation about the self-administration scheme and my medicines and have also received and read the patient information leaflet.

• I agree to:

1. Keep my medication in the locked cupboard provided in my room.

2. Take them as prescribed by the GP.

3. Inform the senior carer/care staff in charge of home if I think I have made a mistake taking my medications.

4. Inform the senior carer/care assistant in charge of home if any visitor or other service user tries to take my medications.

5. Let the senior carer/care assistant in charge of home keep a spare key to the locker.

6. Inform the senior carer/care staff in charge of home of any new medicines.

Service users’ signature …………………………….

Name………………………….

Date …………………………

I have assessed the resident’s suitability for self-administration and have witnessed their signature. Witnessing senior carer/care staff in charge signature……………………………........

Name………………………………………….

Date ……………………………….

Request for Plain Caps on Medicines (copy to be sent to the dispensing Community Pharmacy or Dispensing Doctor) All medicines will be dispensed in child-resistant containers unless the following disclaimer is signed by the service user.

I do not want my medicines dispensed in a child resistant container. Service user signature…………………………………….. Date ………………………………

Service Users Name

Date of Birth

1. Has the Service user been administering medication independently at home or in other services

2. Has self-administration been explained to the service user?

3. Has supply of medication been explained and understood by the service user?

4. Is the service user lucid in thought and judgement, and orientated to time and place? (If “no” self-administration should not be considered)

5. Does the service user understand the requirement for storage of their medicines and are they able to access their lockable cupboard?

6. Can the service user read the labels and other instructions on the medication? Does the service user have good eyesight? If ‘no’ can this be rectified by the use of spectacles and/or large print labels?

7. Has the service user been shown their medicines with an explanation of how they work and how they should be taken?

8. Can the service user demonstrate an understanding of each medication?

a. The name of the preparation

b. The purpose of the medicine

c. Dose and frequency.

d. When and how often to take when required medication “PRN” and the maximum dose.

9. Has the service user been advised to inform care staff if they suspect a side effect?

10. Has the service user been advised that they must inform care staff if they make a dosage error?

11. Has the service user been advised that they must inform care staff on misplacement of key?

12. Has service user been advised that they should inform care staff of any change in their clinical condition?

13. Can the service user open child-resistant containers, blister packs? If No, would the provision of plain caps enable selfadministration?

14. Does the service user understand the protocol for disposing of unwanted medication including sharps where necessary?

Special dispensing requirements/ additional support if needed

15. Tablets out of blisters

16. Plain bottle tops

17. Large print labels

18. Inhalers aids - Is an assessment of inhaler techniques by the asthma nurse/pharmacist needed?

19. Reminder /prompts

Assessed for self-administration:

NAME (in Capital letters) ……………………………………..

Signature: ………………………………. Date of assessment: …………………

Self-administer approved Yes / No

Senior Carer in Charge

NAME (in Capital letters) ………………………………………….

Signature………………………………………. Date……………………

Service Users NAME (in Capital letters) ……………………………………………………

Signature…………………………………………. Date………………

Re assessment Date………………………………………………….

Re-assessment

Service Users Name

Date of Birth

Date

Re-assessment perfomed

Yes/No

Briefly describe any discrepancies & other comments or actions carried out

Re-assessed by

Name: Signature: Date:

Yes/No Name: Signature: Date: Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Yes/No Name: Signature: Date:

Appendix 2: Medication Assessment Form

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

GENDER AGE COMMUNICATION NEEDS

HEIGHT BUILD DIAGNOSIS

CURRENT PLACEMENT REASON FOR LEAVING

HISTORY OF PREVIOUS PLACEMENTS

SELF DIRECTED YES NO IF NO, WHICH AUTHORITY CONTACTS

PROFESSIONAL INPUT / SUPPORT

EMOTIONAL / BEHAVIOURAL NEEDS

COUNSELLING / THERAPY

TRIGGERS LEVEL OF SUPERVISION NEEDED

MEDICATION

LIKES

ACTIVITY PLAN

APPOINTEE

RESIDENT CONTRIBUTION YES NO IF YES HOW

DISLIKES

RELIGION

TASK

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

INDEPENDENT PROMPTS TO START PROMPTS TO COMPLETE FULL SUPERVISION PHYSICAL ASSISTANCE NO ENGAGEMENT

PERSONAL HYGIENE ✓ BOX AS APPROPRIATE

RUN BATH / SHOWER

CHECK TEMPERATURE

GET IN / OUT OF BATH/SHOWER

WASH RINSE

DRY

BRUSH TEETH

USE TOILET

UNDRESSING DRESSING

ABILITY TO WIPE SELF

WASH HAIR

RINSE HAIR

BRUSH HAIR

DRY HAIR

PUT ON DEODORANT SHAVE

CUT/ FILE FINGER / TOE NAILS FASTENINGS

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

MEDICATION ✓ BOX AS APPROPRIATE

DISPENSE MEDICATION

TAKE MEDICATION

ORDER MEDICATION

MAKE APPOINTMENT

ATTEND APPOINTMENT

AWARENESS OF HEALTH

TAKE HOMELY REMEDIES

LOOK AFTER SELF WHEN ILL

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

VERBAL

UNDERSTANDS SPEECH

WRITING

READING

CAN SIGN NAME

CAN COPY WRITE

USE PHONE

USE COMPUTER

CAN ASK FOR HELP / INFO

FOLLOWS VERBAL REQUESTS

FOLLOWS WRITTEN REQUESTS

SHORT TERM MEMORY

CONFUSION

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

NUTRITION & HYDRATION ✓ BOX AS APPROPRIATE

MAKE COLD DRINK

MAKE HOT DRINK

MAKE COLD SNACK

MAKE HOT SNACK

MAKE BREAKFAST

USE MICROWAVE

USE OVEN

MAKE MAIN MEAL

FEEDING

PREPARE MENUS

WASH UP

CLEAN UP

AWARENESS OF FOOD HYGIENE

STORAGE OF FOOD

EXPIRY DATES

SHOPPING LIST

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

SLEEP ✓ BOX AS APPROPRIATE

GOES TO BED

SUFFICIENT SLEEP

GETS UP IN THE MORNING

SET ALARM CLOCK

MAKE BED

KNOWS WHEN TO CHANGE BED

LAUNDRY

IDENTIFY CLEAN CLOTHES

IDENTIFY DIRTY CLOTHES

WASHING MACHINE

HANG OUT WASHING

KNOWS WHEN DRY

WHAT TO IRON

IRON SAFELY

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

MANAGE

BUDGET

USE

UNDERSTAND CHEQUES

USE

COMPLETE FINANCIAL FORMS

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

INDEPENDENT PROMPTS TO START PROMPTS TO COMPLETE FULL SUPERVISION

HOME SKILLS ✓ BOX AS APPROPRIATE

WHEN TO DO HOUSEWORK

TIDY ROOM / HOUSE

POLISH / DUST

HOOVER

SWEEP

BATHROOM

KITCHEN

WASH FLOORS

GO SHOPPING

PAY FOR SHOPPING

UNPACK SHOPPING

PUT SHOPPING AWAY

USE LIGHT SWITCHES

USE PLUGS

OPEN / CLOSE DOORS

LOCK / UNLOCK

DRAW CURTAINS

MANAGE HEAT

HOME SECURITY

GARDENING

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

TRAVEL / LEISURE ✓ BOX AS APPROPRIATE

WALK LONG DISTANCE

WALK SHORT DISTANCE

MOBILITY AIDS

CROSS ROAD SAFELY

ORGANISE TRANSPORT

DRIVE

TAXI

BUS

BUS TIMETABLE STAIRS

UNFAMILIAR PLACES ACTIVITIES

COMMUNITY FACILITIES

MAINTAINS RELATIONSHIPS

MAKE NEW FRIENDS HOBBIES

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

TIME ✓ BOX AS APPROPRIATE

KNOWS NIGHT

KNOWS DAY

KNOWS DATE

KNOWS BIRTHDAY

KNOWS MEAL TIMES

TELL THE TIME

WEARS A WATCH

TIME OF YEAR

SEASON

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

TASK

BEHAVIOUR / SEXUALITY ✓ BOX AS APPROPRIATE

SOCIAL SKILLS

AGGRESSIVE BEHAVIOUR

SEXUALLY APPROPRIATE

UNDERSTANDS SEX

HOW PREGNANCY OCCURS

AWARENESS PUBLIC PLACES

AWARENESS PRIVATE PLACES

UNDERSTANDS VULNERABILITY

UNDERSTANDS RISK TO SELF

UNDERSTANDS RISK TO OTHERS

UNDERSTANDS SAFE SEX

TASK

RESIDENT ASSESSMENT FORM / PRE-ADMISSION

INDEPENDENT PROMPTS TO START PROMPTS TO COMPLETE FULL SUPERVISION PHYSICAL ASSISTANCE NO ENGAGEMENT

EMPLOYMENT ✓ BOX AS APPROPRIATE

FIND SUITABLE EMPLOYMENT

APPLY FOR JOB

PREPARE FOR INTERVIEW

ATTEND INTERVIEW

MEET JOB REQUIREMENTS

FIT INTO WORKPLACE CULTURE

TERMINATE EMPLOYMENT

OTHER TASKS

Appendix 3: Consent Form

Name of Service User:

Address:

Name, Address and Phone Number of GP:

DOB: Assessment Completed by:

Has the service user got capacity to give consent Yes / No

If no: please refer for a best interest decision meeting

Name and Signature of service user Name Signature

I give consent for staff to order and collect my medication on my behalf. A copy of this may need to be shown to the GP and community pharmacy

Appendix 4: Medication Returned to Pharmacy Form

Medication Returned to Pharmacy

Date:

Pharmacy Name:

Pharmacy Location: Name

Pharmacist Signature

Date Received by Pharmacist

Appendix 5: Homely Remedies

HOMELY REMEDY PROTOCOL FOR MEDICINES HELD AS STOCK

Care Home Name: Room number:

Resident Name: D.O.B.

Name of GP Surgery:

Condition for treatment

Pain (mild to moderate), discomfort and/fever. (e.g. aches and sprains, headache, period pain, back pain, tooth ache)

Constipation

Indigestion and heartburn

Diarrhoea

Insect bites and stings

Name of homely remedy stocked by care home as per Mid Essex CCG guidelines

• Paracetamol

NB: Other medicines containing paracetamol may have been prescribed for some patients and this must be carefully checked

• Macrogol (Laxido®/ Movicol®)

• Senna tablets or syrup

• Gaviscon Advance®

• Peptac® Liquid

• Oral rehydration therapy e.g. Dioralyte®

• Hydrocortisone cream 1%

N.B. do not share tube between patients. 15g GSL pack to be used for one patient only and any remaining at the end of the treatment returned to the pharmacy for disposal.

Name of person competing this form:

GP completing form:

Print name: signature:

Suitable for service user named on this form

Does this interact with any other medication, if yes, please note below

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

Date:

Date:

Appendix 6: PRN Protocol

WHEN REQUIRED-PRN MEDICATION PROTOCOL

Care Home Name: Room number:

Name of medication:

Route (e.g. oral, topical):

Name of prescriber:

Resident Name: D.O.B:

Form (e.g. tablet, sachet, capsule):

Strength (e.g. 100mg, 200mg, 50micrograms):

Reason medication prescribed (e.g. constipation, pain):

Dosage:

Minimum time interval between doses:

Maximum dose in 24 hours:

Reason for administration(when the medication should be given): Describe in as much detail as possible: Signs and symptoms to look out for, whether the person can ask for their medicine or if they need prompting or observing for signs of need e.g. non-verbal cues (state if observation charts are being used e.g. behavioural chart, pain charts, stool charts), expected outcome and what to do if the medication does not have the desired effect.):

Any special instructions/ additional information e.g. before or after food, on empty stomach, further interventions required (additional protocol or GP to review):

Predicted side effects: (Use current BNF or patient information leaflet [PIL] to list):

Review date:

Name of person competing this form:

Countersigned by clinician: Clinician speciality:

Date:

Date:

Appendix 7: Risk Assessment for Administration of Medication via Enteral Feeding

Tube by Care Staff Non-Regulated Staff

A risk assessment must be completed by the register nurse/registered practitioner who will take responsibility for delegation of the task, before a decision is made to allow the administration of medication via an enteral feeding tube by a care staff.

The assessment must be completed for each person receiving care and each new task required.

If the answer is ‘no’ to any of these questions an alternative strategy for administration is required.

This form should be left in the person receiving care’s notes/ care record.

Name of person receiving care

NHS number Type of enteral feeding tube

• 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).

1.1 An assessment and individualised care record / support plan has been completed by aregistered practitioner.

1.2 The person receiving care requires medication administration via an enteral feeding tube

1.3 The person receiving care is unable to self-administer

1.4 The person receiving care has no family or informal carers able to administer medication via an enteral feeding tube (where appropriate)

1.5 The person receiving care is stable

1.6 The person receiving care consents to the delegation of the administration of medication via an enteral feeding tube to the care staff, or where they lack capacity to give consent, the principles of the Mental Capacity Act (2005) should be followed(Consent to Treatment (2015) and Mental Capacity Act 2005)

1.7 There are no safeguarding issues

Care Staff

Name:

Name:

Name:

Name:

2.1 Administration of medication via an enteral feeding tube is within the care staffs job description

2.2 The care staff accepts responsibility to perform the task ofadministration of medication via an enteral feeding tube to the required standard following training and assessment.

2.3 The care staff signs to confirm that training was received, understood and that they will comply with the relevant policy and procedures

2.4 The care staff signs to confirm that they understand the necessityof good record keeping

Medication Instruction

Example Lansoprazole

1) Place an orodispersible tablet (or fraction of) in the barrel of an enteral syringe. Replace plunger and then draw up (suck/pull up) 4ml water if the dose is 15mg or less, or 10ml of water if the dose is above 15mg, and 1ml of air.

2) Gently shake and allow the tablet to disperse until a very cloudy mixture is created. This may take five to 10 minutes.

3) Administer the contents of the syringe via the tube. It can be helpful to repeatedly shake the syringe and turn it upside down during administration to keep the granules suspended. Do not crush the pellets with plunger as the syringe empties.

4) Draw up 5ml of water and repeat the process until all the granules have been administered.

5) Flush the tube well following administration.

3.1 Administration of medication via an enteral feeding tube by care staff is to a named person only.

3.2 There is a suitable supply and adequate medication and equipment needed.

3.3 There are suitable disposal facilities for medication and equipment needed.

Other Yes/No

4.1 The service user GP is aware and has provided clear authorisation to administer medicines in this way with information on how the medicines should be prepared and administered safely.

4.2 If the service user care is commissioned by the local authority, the administration of medication via an enteral tube is an approved delegated task.

All aspects of the risk assessment have been completed and control measures achieved.

To be completed by registered nurse/registered practitioner

Name

Designation

Signature

Date

Review date/rationale

Appendix 8: Agreement Form to Consent to Administration of Medication via Enteral Feeding Tube

Details of service user receiving care

Name of service user receiving care……………………………………………....

ID/NHS no…………………………………………………………………………

Statement of registered nurse

I have explained to the service user receiving care that the care staff [ SPECIFY AS APPROPRIATE] assigned to complete this task:

• has undergone a rigorous training programme and is competent in the administration of medication via an enteral feeding tube.

• will be fully supported by the registered nurse/registered practitioner from [COMMUNITY PROVIDER NAME]

I have also explained to the service user receiving care that:

• the team of registered nurses will remain responsible for their nursing care and will review this on a regular basis.

• if the service user’s medical condition changes in any way, care will be given by a registered healthcare professional.

• the service user has the right to withdraw consent at any time.

Signed

Date

Print name

Designation

Consent of service user receiving care

I.................................................................................................................... [INSERT NAME]

understand the statement above, have received sufficient information, have the capacity to consent, have had the opportunity to discuss any questions and consent for the delegated care staff [SPECIFY AS APPROPRIATE] to complete the above indicated routine task/tasks

Signed Date

Print name

Date and time

Appendix 9: Record of Practical Assessment by the Registered Healthcare Professional acting as Assessor

Criteria

Introduction and consent

Standard Infection prevention and control

Checks relevant documentation (medication chart,last documentation, allergy status, Feeding tube site)

Checks that it isthe:

• right person

• right site

• right time

• right medicine

• right dose

• right route

• signature signed by prescriber

• right equipment (enteral syringes)

1. Understands the reason the service user has an enteral tube.

2. Identify the type of enteral tube the service user has.

3. Identify any enteral tube attachments or extension devices required.

4. Understands actions to take in the event of a

Registered nurse/ registered practitioner assessor’s signature

Care staff signature

Assessor’s comments

blocked/damaged/disl odged tube.

5. Understands principles of care such as flushing, skin care, positioning of the service user and good hygiene principles.

6. Can locate & understand the service users healthcare plan.

7. Awareness of local medicines policy (e.g. storage, checking, and handling of medicines).

8. Understands effects and side effects of medicine to be administered Administers each medication as directed Demonstrates correct flushing technique.

Document caregiven

Practical assessment is to be completed on five separate occasions as part of the overall assessment.

The assessor will need to re-evaluate the learner’s competencies and sign off final assessment or re-enter for further training.

FINAL ASSESSMENT AND SIGN-OFF DATE:

I, (print full name) – (REGISTERED NURSE/REGISTERED PRACTITIONER) can confirm that.

(Learner print full name) – (Care Staff) is now considered safe and competent to administer medication via an enteral feeding tube in the community.

Signature of Care Staff: (sign here)

Appendix 10: Medicines Sign-Out/In Record

Medication signed out/ in

SERVICE USER NAME………………………………………………………

11: Risk Assessment for Management of Medicines for Service User Staying at an Alternative Address Risk Assessment for Management of medicines for Residential service user staying at an alternative address.

1 Are all medicines clearly labelled?

2 Do the labels correspond with the current medication list?

3 As-required medicines – Are there clear instructions regarding when they are to be used, the correct dose and maximum daily dose or minimum frequency? Administration

4 Can the service user self-medicate safely

5 If the service user cannot self-medicate, is there a family member, friend or carer

6 If the service user has taken medication to an alternative address previously, has it all been returned to the care home address with them?

7 Are you confident the medication will be taken /given appropriately as per the directions?

8 By the service user?

9 By family/ friend or carer?

the servicer user prescribed insulin?

Appendix 12: Overview for Administering Medication at Fern Lodge and Supported Living

1. All staff MUST ensure they have read and signed the handover book from the last date they were at the premises before administering any medication

2. All staff must ensure they have all the correct equipment needed for administration in their homes/rooms including medication folder, pen, medicines pots/spoons/syringes, Personal Protective Equipment (PPE), drinks or yogurts/food and counting devices

3. Staff must follow the 6 RIGHTS, (right person, right route, right time, right dose, right medication, right to refuse)

4. All staff must check Medication Changes Form for any changes in medication doses, any new medication started, any medication stopped or for any interim medication (Antibiotics, steroids, pain relief etc)

5. Staff should ensure they complete the medication administration form with names and signatures and temperatures where appropriate.

6. Staff should check for any Vitamins/Homely remedies to be administered

7. Staff should check if there is particular advice on how to administer medication if it contains two different Hormones or needs to be taken with or without food

8. Staff should start with page 1 of the MAR chart and ensure that the label matches the MAR chart directions.

9. Staff should check the route of the medication and follow topical creams charts for creams and ensure directions are followed for oral liquids, ears and eye drops.

10.Staff should check against PRN protocols if any PRN medications need to be administered.

11.When administering tablets staff should clearly count the tablets before administering ensuring that the count is correct. Staff should then POP the tablets into a medication pot and ensure a DOT is placed within the box and recount the tablets. The box should then be put aside from other medications. Staff should continue this process for all tablets on the MAR chart.

12.Staff should check all popped medications against the list and MAR chart and ensure there are the correct number of tablets in the pot.

13.Staff should then administer all medications, tablets/capsules, liquids, drops and creams.

14.Staff should always check the bottom of the medicines pot to ensure all tablets have been taken.

15.Staff should then sign all administered medication, ensuring that EVERY medicines on the MAR chart for that time has a signature or a code if required. NO BOXES should be left blank. Staff should ensure the correct codes are being used Any code used must have information documented on the carers notes in the MAR folder and in their daily notes.

16.Staff should ensure they write in the daily communication record the time and document that all medication taken was seen – Any difficulties, refusals or concerns should also be documented.

17.Staff should immediately raise any errors they have noticed on the MAR chart from previous administration. This includes:

a. Pharmacy/111/GP should be contacted as appropriate

b. Team leader/manager notified when on duty

c. DATIX completed

18.Another staff member should check the MAR charts and ensure all medication has been signed.