medicines policy & procedures for care homes

Care HomeUpdated by Oyepero Olasehinde-williams (care homes Pharmacist) Feb 2019 With acknowledgement to Walsall CCG
NHS Castle Point and Rochford CCG NHS Southend CCG www.castlepointandrochfordccg.nhs.uk
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www.southendccg.nhs.uk
Medicines’ Policy &
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CONTENTS
3. CONSENT ................................................................................................... 4
6. RECEIPT OF MEDICINES .......................................................................... 5
7. STORAGE OF MEDICINES ........................................................................ 5
8. REFRIGERATED MEDICINES .................................................................... 5
9. KEY SECURITY .......................................................................................... 5
10.CONTROLLED DRUGS (CDS) .................................................................. 6
10.5 Discrepancies ...…………………………7
11. OXYGEN…………………………………………………………………………7
13. REFUSAL .................................................................................................. 9
15. COVERT ADMINISTRATION .................................................................... 9
16. CRUSHING TABLETS ............................................................................ 10
18. EMERGENCY ADMINISTRATION OF MEDICINES ............................... 10
19. WHEN REQUIRED (PRN) MEDICATION ............................................... 10
19.1 Ordering PRN medication…………11
19.2 Receipt of PRN medication……… ..11
20. HOMELY REMEDIES .............................................................................. 12
22. ADVERSE DRUG REACTIONS ............................................................. 13
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1. Introduction
This policy is intended to cover the prescribing, ordering, storage and administration
of all medication used in the Care Home.
The policy takes into account the requirements laid down by the Medicines Act 1968,
The Misuse of Drugs Act 1971, The Misuse of Drugs (Safe Custody) Regulations and
subsequent amendments to these, The Nursing and Midwifery Council Guidelines for
the Administration of Medicines and The Care Standards Act 2000.
It also reflects the recommendations made in the NPA Guide to Good Practice in the
Management of Controlled Drugs in Primary Care (England) Second Edition
February 2007, the Handling of Medicines in Social Care – Royal Pharmaceutical
Society of Great Britain, The Mental Capacity Act 2005 and the Nursing &
Midwifery Council Guidelines.
2. Policy Aims The aim of this policy is to
Ensure that all staff that are responsible for the administration, ordering and
storage of medication are fully aware of all their roles and responsibilities.
To provide a framework with clear guidelines for use when dealing with
medication.
It is the responsibility of the Registered Manager to ensure that all staff are aware of
this policy and that suitable training is made available, in order that correct and safe
practice is carried out at all times.
It is the responsibility of each member of staff to be accountable for their actions in
relation to the procedures within this policy
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3. Consent Consent for care staff to handle their medicines must be obtained from all residents. If a
resident is unable to make an informed decision, then staff must ensure the Mental Capacity
Act 2005 is adhered to.
4. Requesting Prescriptions and Medicines Medication should be ordered by the manager or a designated senior member of staff.
Enough medication should be ordered to last for 28 days.
(Please note that most GP practices will normally require 24-48 hours turn around time for
prescriptions. Please check with the relevant practices how much notice they will need.)
On the start of the second week in the 28-day medication cycle the designated member of
staff should create an order using a copy of the MAR chart and FP10 repeat order form.
For each resident check the amount remaining of each medication. If there is enough to last
till the next order day, i.e. 3weeks of current cycle and 4weeks of next cycle (7weeks) worth
of medication then there is no need to order more.
When Required (PRN) medication should not be dispensed in a Monitored Dosage (MDS)
compliance aid, and should only be re-ordered when needed. In date medication should not be
destroyed as this can result in substantial medicines waste. Indicate on the copy of the MAR
chart that it is not required along with the reason why. Clearly identify all medication that is
required.
Before taking/ sending the order to the GP practice a photocopy of each order should be made
and retained at the home.
Once the prescriptions have been signed by the GP they should be returned to the home so
that they can be checked against the photocopy of the order. If any discrepancies are noted the
GP practice can then be contacted so that errors may be put right before the prescription goes
to the pharmacy to be dispensed.
When the prescriptions have been checked they can be taken to the pharmacy (some
pharmacies offer a collection service). This should be done in sufficient time for the
medication to be prepared and delivered in time to start the new supply.
Staff involved in the administration of medicines must ensure that they inform the Care
Manager or designated member of staff if any medication appears to be in short supply.
Name of supplying pharmacy………………………………………….
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5. Out of Hours treatment Medical advice can be obtained from NHS Direct on 0845 4647 or NHS 111
Medication helpline for Care homes in Mid and South Essex STP on 01245922001 or email
[email protected]
6. Receipt of Medicines Medicines should be received into the home by a designated member of staff.
Newly received medication should be checked and put away as soon as possible and should
not be left lying around.
Once the new medication has been received into the home it should be checked against the
photocopies of the order and against the MAR chart. Any discrepancies should be checked
with the supplying chemist before the medication is administered.
7. Storage of Medicines Medication should be stored in a locked cupboard in a secure area, free from excess heat and
strong sunlight. A room thermometer should be in place to monitor the temperature and
ensure that the medicines are not stored above 25°.
If possible externally applied medicines should be stored separately.
Where a medicines trolley is to be used it must be either chained to the wall or stored in a
locked drug room when not in use.
Any waste medicines waiting for collection by the pharmacist or waste disposal company
should also be locked away.
8. Refrigerated Medicines A dedicated medicines refrigerator should be put in place and should be fitted with a digital
thermometer to record the daily maximum and minimum temperatures. A record should be
kept of the daily readings and should include the signature of the care worker taking the
readings. Any unusual results should be reported to the manager or a senior member of staff.
No food should be stored in the medicines fridge to minimize the risk of contamination and
the fridge should not be overfilled as this increases the chance of changes in temperature.
The refrigerator should be fitted with a lock and should be regularly cleaned and defrosted
and a record kept.
If the refrigerator breaks down or the temperature exceeds 8° advice must be sought from a
pharmacist or the medicines manufacturer to establish whether the medication will still be
suitable for use or if it needs to be discarded and a new supply obtained. Similarly, if a minus
reading is recorded this means that the fridge has gone below freezing point and the medicine
must be checked to ensure that it hasn’t frozen. If it has a pharmacist or the manufacturer
must be contacted to ensure the medication is still fit for use.
9. Key Security The number of sets of keys and care workers with access to them should be limited and a
designated member of staff should be responsible for their safekeeping during each shift.
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10. Controlled Drugs (CDs) CDs are prescribed and dispensed for individually named residents, in the same way as other
prescription medicines. However due to the special legal requirements extra time should be
allowed for prescriptions to be written. Prescriptions that do not comply with the legal
requirements may have to be sent back to the prescriber for altering before they can be
dispensed.
10.1 Storage
CD’s must be stored in a metal cupboard which complies with the Misuse of Drugs
(Safe Custody) Regulations 1973. This includes the use of a heavy gauge metal
cabinet with a double locking mechanism. This cabinet should be reserved for the
storage of controlled drugs only.
Residents who are responsible for storing and administering their own medication, as
they would in their own home, do not need to use a CD cabinet but, as with their other
medication, there should be a lockable, non-portable draw or cupboard in their room.
10.2 Records All care homes should keep a record of residents own CDs in addition to the records
maintained on Medicines Administration Record (MAR) charts. This should be a specially
purchased CD register.
The register should be a bound book with numbered pages and a separate page should
be used for each resident’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 the receiving nurse or authorized 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.
10.3 Administration Designated and appropriately trained staff only, must administer Controlled Drugs. 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 resident’s name, plus 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
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Once the nurse or trained carer has witnessed the resident taking the medication, the
resident’s administration chart and the register can be signed by the nurse / trained
carer and the witness
The administration process should be fully completed for each resident, before
moving on to the next resident.
10.4 Disposal of Controlled Drugs For homes providing personal care only, unwanted controlled drugs should be returned to the
supplying Pharmacy for disposal. The form and quantity of the CD being returned should be
recorded in the waste book and the pharmacist should sign for them on receipt. A record of
the return should also be made in the CD register by an authorised member of staff and should
be signed by a witness. If pharmacy staff collects the CDs it is good practice that they should
sign for them in the register at the time of collection.
Homes providing Nursing Care should use the services of a licensed waste management
company as they do for all their other medication waste. CDs should be denatured first using
a special denaturing kit which can be obtained from a pharmacy.
10.5 Discrepancies Routine checks of all CDs held, and the recorded running balances, should be carried out by
two nurses, or other authorised members of staff, on a regular basis, e.g. monthly, and a
record kept
Where a discrepancy is found, it should be reported immediately to the registered
manager who should investigate promptly
If the discrepancy cannot be resolved, the advice of the local pharmacist should
be sought and the CQC local office informed
The Controlled Drugs Accountable Officer (CDAO) should also be informed
email: [email protected]
Cambridgeshire and Peterborough at https://www.cdreporting.co.uk
10.6 Non Prescribed Controlled Drugs If staff suspect that a resident has brought an illicit substance into the care home advice may
be obtained from the local police. Small quantities may be destroyed in the home providing
staff fully document exactly what has taken place and also have a witness signature.
11. Oxygen Oxygen will be prescribed for each individual resident if the prescriber considers it necessary.
Advice on storage and administration may be obtained from the supplier; the following
guidelines should also be followed:
Cylinders must be stored under cover and not subject to extreme temperatures
The storage area must be clean, dry, well ventilated and away from highly flammable
liquids, combustibles and sources of heat and ignition
Cylinders must be stored upright and secured by way of a chain to the wall
Empty cylinders must be stored separately and easily distinguished from full
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The statutory warning notices must be displayed in any room/area where oxygen is
used or stored
Oxygen therapy must only be discontinued or the flow rate altered by the direction of
the prescriber
Equipment must be handled by trained staff or under the supervision of trained staff
only
Regular stock checks will be carried out with particular attention paid to expiry dates
12. Administration of Medicines Confirm that you are giving the right medicines to the right person. A robust system
for identification should be put in place and the use of recent photographs is
recommended.
All equipment should be assembled and ready before starting. This should include:
- All medication to be given at that time of day including fridge items and PRNs.
- Medicine tots, water, cups, gloves.
- The MAR chart
Ask the person if they want their medicines before they are removed from the
packaging. If the medication is refused the person should not be forced to take it and
neither should it be given covertly by hiding it in food or drink. Instead it should be offered again a little while later. If the person continues to refuse the manager or lead
carer should be informed and the GP will also need to be informed.
Ensure that the label on the medication matches that on the MAR chart in all respects.
Check that the dose is clear and if the directions say as required, the use of a PRN
protocol is recommended to ensure that you understand the circumstances under
which they should be offered. E.g. if the tablets are for pain relief establish whether
the person has any pain before offering them. Care should be taken to ensure that the
medication has not already been administered by another care worker. If a dose of a
PRN medicine is administered it should be recorded on MAR and a note of reason
and outcome recorded at back of MAR.
Tablets/capsules should be prepared by a clean method. That is, they should be
pushed out of their packaging directly into a medicine pot and should then be handed
to the person. Syrup or mixtures should be administered using the spoon or measure
provided by the pharmacist. Some medicines can be harmful on direct contact with
the skin in which case plastic gloves should be worn.
Once the person has taken the medicine sign the MAR chart in the correct column by
the correct medication and administration time. If the medication has been refused
the MAR chart should also be endorsed with the appropriate code as indicated on the
bottom of the MAR chart and if necessary, a note made on the back of the sheet
explaining why it was refused.
If the medication has a variable dose e.g. 1 or 2 tablets the quantity given must be
endorsed on the MAR chart, and a clear policy of when to give 1 or when to give 2,
for each medication with varying dose.
Once the person has received all the medication due to them at that time and all the
entries have been made on the MAR chart the procedure should be repeated with the
remaining residents.
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13. Refusal Persistent refusal to take a medication should be reported to a senior member of staff and
investigated. It may be that they do not like the taste or are finding it difficult to swallow. In
this case the GP should be asked to review their medication to see if it is still required or if an
alternative could be prescribed.
14. Self administration Residents should be encouraged and supported to self administer and store their own
medicines. To do this, a locked cabinet should be provided so that they may be stored safely
and a robust risk assessment process must be in place to determine whether the resident is
capable of self administration.
Further assessment should take place initially on a weekly basis and then periodically
thereafter once competence has been confirmed.
It is important to obtain signed consent from the resident before proceeding and after the
process has been fully explained.
14.1 Procedure for self administration Once the resident has been assessed and has signed a consent form they should be given the
key to their own locked medication cupboard.
The resident should take their medication without supervision under their own responsibility.
Overall responsibility to ensure that the resident is suitable for self administration remains
with the home
Although medication is not being administered by care home staff the quantity received into
the home should still be recorded on the MAR chart so that compliance checks can be made
and recorded. These should include the quantity of doses and should be repeated every 28
days to ensure that the right quantity of medication is being taken. A note of the date of
the check and any issues should be recorded.
It should be stressed to the resident and any relatives/friends that purchased over the
counter remedies should not be taken without discussion with the pharmacist or
nurses to consider drug interactions.
If discrepancies are found compliance checks should be made weekly and the resident
re-assessed.
Controlled drugs can also be part of a self-administration scheme. They should be
treated the same as other medication and kept in secure storage. An entry should be
made into the Controlled Drugs register to record what drugs have been received into
the home and given to the resident to self administer.
15. Covert Administration All residents have the right to refuse medication and this right should be respected.
If the resident has capacity as defined by the Mental Capacity Act 2005 then they can not be
forced to take their medication by administering it covertly.
Assessment of capacity should be undertaken by a multidisciplinary team and a decision
should be made that is in the best interest of the resident. All assessments and decisions
should be clearly documented in the residents care plan and should include a risk assessment
and a review date. If it is decided that the medication needs to be administered covertly in
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food or drink the reasons for the decision should be documented and a pharmacist should be
consulted to ensure the stability of the medication.
Guidance on the Mental Capacity Act can be found on the CCG and CQC website. (See
appendix 1b for Authorization form for crushing if administering covertly)
16. Crushing Tablets While it is always better to avoid crushing tablets or opening capsules there are some cases
where it is unavoidable.
If a resident has problems swallowing or has other problems that make tablets or capsules
unsuitable, rather than asking for a liquid special other alternatives should be tried. For GP
practices that have a practice pharmacist working with them, they can be contacted to give
advice on the best way to deal with the problem. This could mean looking at alternative
medications or crushing tablets. If it is decided that the only alternative is to crush the tablets
then the GP can issue a written directive, either by writing on script or filling out on form.
(See appendix 1).
By issuing this directive the GP is taking responsibility for the medication to be administered
in this way. As long as advice has been sought and the crushed tablets are not being hidden in
food as a means of Covert administration which you need to approach differently (see above
15.Covert administration).
17. Specialist Administration Techniques Care workers should only administer medicines that need specialist techniques if they have
been trained by a healthcare professional who is satisfied that they are competent to carry out
that task.
Rectal administration e.g. suppositories such as Diazepam for epileptic seizure
Insulin by Injection
Giving Oxygen
Other specialist techniques such as the administration of injections and enemas or the
insertion of catheters fall within the responsibility of community nursing services and should
not be undertaken by care home staff.
Care workers have the right to refuse to assist with the administration of medication by
specialist techniques if they do not feel competent to do so.
18. Emergency Administration of Medicines If a care home has a prescription for emergency medicines e.g. adrenaline for peanut allergy,
then a clear resident specific procedure should be written and staff trained in the handling of
such medicines.
19. When Required (PRN) medication PRN medication should be dispensed in its original container and NOT put into a Monitored
Dosage System (MDS). This means that if there are any left unused at the end of the 28-day
cycle they can be carried forward to avoid wastage as long as the following procedure is
followed.
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2. The medication is still within its expiry date.
3. The patient still requires the medication. -To determine if the patient still requires the
medication the GP practice should be asked to review them. The GP practice should
be informed if the patient is refusing the PRN medication and it is then up to the
prescriber to decide if it needs to be discontinued. Regular review is particularly
important for those patients that do not have the mental capacity to refuse PRN
medication as it is then difficult to judge whether they still need it. PRN medicines
should not be stopped without medical advice.
Once this has been established, the named member of staff should enter the name and
quantity of the medication on the patient’s new MAR sheet. As if the entry is handwritten, a
second member of staff should check the entry and also sign the MAR sheet as a witness.
Alternatively, a second MAR sheet may be started purely for PRN medication for each
individual resident, however the number of MAR charts in use should be kept to a minimum.
Each entry should record
2. The strength
3. The quantity being carried forward
4. The reason the drug was prescribed and how much and how many times a day it is to
be taken e.g. one to be taken THREE times a day when required. And any other
relevant information
5. Each entry should be witnessed by a named member of staff and the chart signed
If a separate PRN sheet is to be used it should be kept with the regular medication sheet and it
should be remembered that:
PRN medication should continue to be offered to the resident at the appropriate time or
at the resident’s request.
19.1 Ordering PRN medication On the appropriate day the member of staff responsible for ordering medication will look at
each item for each resident. They should determine whether there is enough PRN medication
left to be used the following month. If the patient has been refusing the medication resulting
in an overstock, then the medication should be carried over from one month to the next and
not disposed of. If this is the case, then the item should not be ordered that month from the GP
practice (this can only happen if the medication is in its’ original container).
A note should be made against the item on the repeat prescription when ordering; explaining
why it will not be required that month and item should not be ticked.
It is the responsibility of the staff member assigned to order medication to determine if there
is enough PRN medication left to last the coming month. This can be done by looking back at
the MAR chart to see how many times the medication has been required during the past
month, they should then be able to calculate how much is likely to be required in the coming
month.
It is good housekeeping to ensure that PRN medications do not run out in the middle of the
month which would mean that a prescription would then have to be obtained for a new
supply.
Once the prescription is ready at the GP’s surgery, it should be checked at the Care Home
before being sent to the pharmacy for dispensing. This is to ensure that there has been no
mistakes made and that the prescription is for the required medication.
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19.2 Receipt of PRN medication
New supplies of PRN medication should be handled in the same way as regular medication. It should be checked as soon as possible after receipt by a designated member of
staff and the MAR sheet filled in as detailed above.
PRN medication should NOT be supplied in a MDS (Monitored Dosage System) but should
be in a separate container.
When dealing with PRN medication it is good practice to complete a PRN protocol (see
appendix 3), obtaining the following information from the Prescriber. This information can
also be included on the MAR chart and in the care plan.
The following information must be available to all members of staff who may need to
administer medication:
2. How much to give
3. How many times a day it can be given
4. The maximum daily amount
5. The time interval between doses e.g. not more than every four hours for pain relief.
6. Side effects, especially the ones that would need GP to be contacted.
20. Homely Remedies Before any homely remedy is administered there must be an agreement with the residents’ GP
that the GP is happy for the patients to be treated with these remedies.
This agreement should state the type of ailments that may be treated and the remedies that
may be used.
Indigestion
Coughs
Constipation
Diarrhoea
Skin Conditions- since creams and ointments should not be shared between patients and are
therefore unsuitable to be used as homely remedies there is no recommendation for skin
conditions.
For Homely remedy agreement form, see appendix 2.
An agreement should be signed by the GP for individual patients to ensure that the proposed
remedies will not interact with any medication they are already on.
Once an agreement with the GP is in place these remedies may be administered by a trained
nurse or appropriately trained care staff.
A copy of the agreement should be kept in the residents notes.
20.1 Recording 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 residents’ notes.
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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
Annotated as “Homely Remedy”
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.
21. Medicines Administration Error If an error is made advice must always be sought immediately no matter how trivial the error
may seem.
Any error must be reported to the person in charge or their deputy straight away and the
resident’s GP should be informed. If the GP practice is closed, then advice should be sought
from the out of hours’ service or NHS direct.
Details of the error should be recorded in both the accident book and the resident’s notes and
the person’s relatives should be informed.
If the resident has a serious adverse reaction then ring 999 and request an ambulance,
ensuring all the information regarding the error is available
There should always be a review to establish how an error occurred in order to prevent a
similar error happening again. To reduce the chance of errors occurring staff must: -
Keep their knowledge up to date.
Avoid distractions whilst giving out medication.
Pay attention to residents’ identification.
Ensure a resident has taken the medication given and not left it or spat it out.
If in any doubt do not give the medication until clarification has been obtained.
If a person has been placed at risk of harm or the error involves a controlled drug it must be
reported to the Care Quality Commission (CQC) and in the case of an error involving a
controlled drug to
• Drug concerns/incidents in Essex, Norfolk, Suffolk, Cambridgeshire and
Peterborough to be logged in at https://www.cdreporting.co.uk
22. Adverse Drug Reactions Medication is chosen to produce a specific effect; however unwanted side effects may also
occur.
Staff should report any unusual or adverse effects to the pharmacist or doctor.
Staff should regularly review resident’s daily records to identify patterns of
behaviour which may be linked to the medicines they are taking.
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APPENDIX 1a

medicines policy & procedures for care homes

Documents