standard operating procedure for medicines management in

Standard Operating Procedure for medicines management in Care Homes in North Wales

FINAL April 2020 (Paper copies of this document should be kept to a minimum and checks made with the electronic version to ensure the

version to hand is the most recent.)

BCUHB Pharmacy and Medicines Management

Standard Operating Procedure(SOP) for medicines management in

Care Home Settings in North Wales Date to be reviewed April 2021 Number of pages 43

Author(s) Sioned Rees, Catherine Ellis Sue Randles Teresa Bushell Hayley Jones Eiriann Turner Val Bamber

Author(s) title Pharmacist Gwynedd Local Authority Pharmacy Technician Pharmacy Technician Medicines Management nurse Medicines Management nurse Medicines Management nurse

Responsible department/director Pharmacy and Medicines Management

Approved by BCUHB Medicines Policy, Procedures and PGD sub group and BCUHB Drugs and Therapeutics Group

Date approved December 2016 updated April 2020 – COVID 19

Date activated (live) December 2016

Date EQIA completed 27 April 2016

Documents to be read alongside this policy

1. Betsi Cadwaladr University Health Board and North Wales Local Authorities Joint Agreement for a Code of Practice for the Management of Medicines in health and social care settings May 2016

2. Standards of best practice and standard operating procedures for medicines management for all care settings for adults April 2020

3. BCUHB Medicines Policy MM01 http://howis.wales.nhs.uk/sites3/page.cfm?orgid=475&pid=57485

4. Dougherty L. & Lister S. (2011) The Royal Marsden Hospital Manual of Clinical Nursing

5. Royal Pharmaceutical Society (RPS) Professional Guidance on the Administration of Medicines in Healthcare Settings. (January 2019)

6. Royal Pharmaceutical Society (RPS) Professional guidance on the safe and secure handling of medicines (2018)

First operational

2016

reviewed April 2020

Changes made yes/no

Yes SOP’s removed

PROPRIETARY INFORMATION This document contains proprietary information belonging to the Betsi Cadwaladr University Health Board.

Do not produce all or any part of this document without written permission from the BCUHB.

SOP approved/rejected

Date

Approved CAG, MPPP and D&T June 2020

http://howis.wales.nhs.uk/sites3/page.cfm?orgid=475&pid=57485




These attached Standard Operating Procedures have been produced to be adopted by each Care Home as appropriate to their practice.

It is recommended that any standard operating procedures adopted are reviewed at least annually or when there is a change in relevant care workers; an incident has occurred, and each time there is new or amended legislation or guidance. The National Minimum Standards for Care Homes for Older People in Wales state “The registered person shall make arrangements for the recording, safe keeping, safe administration and disposal of medicines used in the course of provision of personal care to the Resident.”

PAGE

Contents 1,2

1. Self administration of medication by residents ( Helping Resident to look after and take their medicines themselves)

4,5,6

1a Assessment form for self administration 7,8,9

2. Ordering medication 10,11

3. Receipt of medication 12,13

4. Storage of medication 14,15

5. Control of Substances Hazardous to Health Regulations (COSHH) 16

6. Oxygen 17

7. Administration of medication 18,19,20

8. Verbal orders or messages relating to medication dosage change 21

9. Medication record keeping in Care Homes 22,23,24

10. Disposal / return of medication 25,26,27

11. Medication administration error 28,29

12. Covert administration of medication 30,31

13. Use of medication away from home 32

14. Transfer of Resident to another setting (e.g. discharge from or admission to hospital)

33

15. Homely Remedies 34,35,36,37,38

16. Controlled drugs in Care Home

17. ‘When required’ medication(PRN medication) are administered




1. Self administration of medication by Residents (Helping Residents to look after and take their

medicines themselves)

Scope The National Minimum Standards for Care Homes for Older People states that residents 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 resident 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 residents prescribed inhalers, insulin, creams

or new residents who are confident with their medication.

Process for assessment for self administration of medication (including non prescribed

medication by a resident)

Action Rationale

1. Consider whether there are any constraints on

self‐administration and, if so, how they might be

overcome. Discuss this with appropriate members of the

multidisciplinary team. Residents must be issued with a

patient information leaflet explaining the scheme before

consent to take part is sought. (Page 5)

To promote successful and safe

self‐administration and ensure that

medicines are dispensed and

labelled appropriately for the

patient's needs

2. The resident’s medication is required to be stored in a

locked cupboard in their own room. The resident holds

the key to their own locked medication cupboard, with

the care workers also having a key to access.

To ensure secure storage.

3. Carry out an assessment of the resident’s ability to

self‐administer medication using the assessment form

on Page 6. Any resident requiring plain tops must also

sign a disclaimer (Page 5)

To ensure resident is competent to

self administer

4. The resident must give signed consent to be included in

the scheme.

5. The assessment form and the consent will be filed in the

residents records.

6. Discuss with the resident their medication and any

problems they may be having with the regimen.

Document discussions in the care plan. Teach any

special skills required, for example correct use of

aerosol inhalers

To promote the informed

commitment and involvement of

patients in their own care, where

appropriate. To ensure that

treatment is received as intended

7. Compliance checks/ reassessment should be carried

out for the residents who are self administering

medication

daily for the first 3 days,

weekly thereafter

If there are any discrepancies

A note of the date of the check and the signature of the

person completing the check should be made and any

issues documented. (Page 8)

A MAR or equivalent chart, if

available, can be used for this

purpose.

8. The resident should be reassessed and referred to the To identify further learning and




appropriate care home manager or health care

professional if there are:

changes to medication

a change in clinical condition

on review of the resident’s care plan

if difficulties arise

poor compliance

at the request of the resident

Liaise with the resident’s family or advocate

teaching needs and modify care

plan accordingly

9. Only prescribed medication is approved for self

administration. All purchases of ‘over-the-counter’

medicines by relatives/friends must be discussed with

the pharmacist or nurse to consider risk of drug

interactions.

Notes

1. The Care worker undertaking the assessment must have received training and been assessed as

competent in the assessment process for the self administration of medication.

2. Overall responsibility for ensuring that the resident remains suitable for self administration remains with

the Care Provider.

3. The residents care plan and daily record must be clearly marked that they are self administering

medication.

4. The resident’s progress or other relevant issues including monitoring should be documented in the care

plan/daily notes.




Resident 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 assistant 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 resident 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 assistant in charge of home of any new medicines.

Residents signature ……………………………. Name…………………………. Date ……………………………….. I have assessed the resident’s suitability for self administration and have witnessed their signature. Witnessing senior carer/care assistant 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

resident.

I do not want my medicines dispensed in a child resistant container.

Residents signature…………………………………….. Date ………………………………

Assessment form for Self Administration of Medication




Assessed for self administration: NAME (in Capital letters) ……………………………………..

Residents Name: NHS number:

Date of Birth:

Question YES/NO

Comments

1. Has self-administration been explained to the resident?

2. Has supply of medication been explained and understood by the resident?

3.

Is the resident lucid in thought and judgement, and orientated to

time and place? (If “no” self administration should not be considered)

4. Does the resident understand the requirement for storage of their medicines and are they able to access their lockable cupboard?

5.

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

6. Has the resident been shown their medicines with an explanation of how they work and how they should be taken?

7.

Can the resident 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.

8. Has the resident been advised to inform care workers if they suspect a side effect?

9. Has the resident been advised that they must inform care workers if they make a dosage error?

10. Has the resident been advised that they must inform care workers on misplacement of key?

11. Has resident been advised that they should inform care workers of any change in their clinical condition?

12. Can the resident open child-resistant containers, blister packs? If No, would the provision of plain caps enable self- administration?

13. Does the resident understand the protocol for disposing of unwanted medication including sharps where necessary?

Special dispensing requirements if needed Comments

14. Tablets out of blisters

15. Plain bottle tops

16. Large print labels

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

18. Reminder prompts




Signature: ………………………………. Date of assessment: ………………… Self administer approved Yes / No Senior Carer in Charge NAME (in Capital letters) ………………………………………….. Signature………………………………………. Date…………………… Resident NAME (in Capital letters) ……………………………………………………

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

Re assessment Date




Self Administration Reassessment (To be filed in resident’s notes)

Residents Name: NHS number:

Date of Birth:

Date Re-assessment

performed

Briefly describe any discrepancies &

other comments or actions carried out

Re-assessed by

Yes/No

Name: Signature: Date:

Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No


Yes/No





2. Ordering medication

Action Rationale

1. The care home must take precautions that the

stock levels of medication for each resident are

kept at an appropriate level dependent upon

need

On admission, written confirmation of the

medication the resident is taking should be

obtained. E g current repeat slip

2. Check repeat prescription against current MAR

to determine need in the forthcoming month.

Care should be taken to ensure that only

the medication required is requested to

avoid stock piling medication. E.g.

Paracetamol

3. Medicines are ordered on a four weekly cycle

usually at the start of week two.

4. The repeat medication can be ordered by:

My health online – internet ordering system or

By the resident or staff member completing

the repeat slip on the WP10 green

prescription form and delivering the form to

the GP surgery within two working days of

requirement of a new supply of medication.

5. Named care workers from the home must collect

the repeat prescriptions from the surgeries, and

check each prescription against the Resident’s

record in the home to ensure that items are

correctly listed.

6. Any discrepancies must be brought to the

attention of the GP.

7. Details should be provided on where orders

should be sent, in which format, the time required

by each surgery to process the requests and

other relevant details

The manager may select one pharmacy

where the home obtains medicines on

behalf of its residents in order to ensure

continuity of care.

8. Details of medication ordered for each resident

should be kept within the care home. This should

include:

Date ordered.

Name, strength and dosage.

Quantity.

Resident’s name.

Signature of member of care workers ordering and checking.

9. For Controlled Drugs requests, the back of the

prescription must be completed by the care

workers of the home before sending to the

pharmacy.

Scope - Staff should have protected time to order medicines and check delivery. At least two

members of staff should be trained to order medication and check receipt to ensure continuity in terms

of sickness and annual leave.




Notes

1. It is unacceptable to return unused medicines each month to the supplier, whilst requesting further supplies.

2. Care workers must take precautions that the stock levels of medication for each service user are kept to an

appropriate level. Hoarding of excessive quantities of medication should be avoided and when necessary the

line manager should contact the resident’s GP in order to amend prescription quantity or request a medication

review.




3. Receipt of medication

Scope

At any given time the home should be able to identify the medication prescribed/obtained for each individual

resident. On admission to the home written confirmation of the residents medication should be obtained

from an authoritative source i.e. GP practice, hospital, relative.

Action Rationale

1. All medication brought into the home from

whatever source should be recorded. This

includes prescribed medication (regular and

acute), discharges from hospitals and

medication from the residents own home such

as homeopathic, herbal and over the counter

(OTC) medication

2. On arrival at the home medication should be

checked for accuracy against:

Original medication request

Residents’ current MAR or equivalent

chart

New MAR or equivalent charts for monthly

orders

3. For receipt of each medication the following

checks are required:

Resident for whom the medication is

prescribed (or purchased)

Name, strength, dosage, form, quantity

and date received.

A patient information leaflet (PIL) is supplied

with each medicine (including those supplied

in monitored dosage systems). Care

workers must ensure that this leaflet is

available to the resident, and a current copy

is placed in the PIL file for care workers

reference.

Medicines must be appropriately labelled

4. Any discrepancies should be clarified with the

dispensing pharmacy or surgery. If there is

an error in the dispensing of the medication,

then an incident form must be completed http://howis.wales.nhs.uk/sitesplus/documents/861/BCUHB%20

PCSU%20Incident%20Reporting%20form%20April%202016.p

df

For Conwy and Denbighshire /Central area

contact PCSU, Clinical Governance

Department, Mandy Casey

([email protected] 03000 856121)

For Flintshire and Wrexham/ East area

contact:- PCSU, Clinical Governance

Department, Richard Waterson

([email protected]

03000856670)

For Gwynedd and Anglesey/ West area contact

http://howis.wales.nhs.uk/sitesplus/documents/861/BCUHB%20PCSU%20Incident%20Reporting%20form%20April%202016.pdf



mailto:[email protected]





:-PCSU, Clinical Governance Department:-

Mary Cottrill Mary Cottrill

([email protected] 03000 852300)

5. If a label becomes detached from a container,

or is illegible, care workers must obtain advice

from the pharmacist. Until then, the original

container should not be used.

To ensure correct identification of the

medication, dosage etc.

6. A record should be made of the receipt of all

medication in accordance with the homes

policy

7. When medication is received, attention must

be paid to any special storage requirements

or hazardous medication.

Notes 1. Do not change the information printed on the dispensing label on the container of the medication.

2. In the case of multiple containers, each container must be labelled. For example, on medications which

have an inner container and an outer box (e.g. eye drop bottles, cream and ointment tubes) the label

should be applied to the item as well as the outer box. In the case of monitored dosage systems, a new

label should be affixed to each supply

3. Pharmacists must supply all medicines in child resistant packaging unless a written request is sent to

the community pharmacist or dispensing doctor if they have difficulty opening packaging, or if they just

prefer not to have child resistant packaging

4. Non prescribed medicines (OTC, complementary and homely remedies) must be stored separately from

residents’ own medication, in a locked cupboard and must be clearly marked HOMELY REMEDY. If

these are needed on a regular basis, then residents self administering can store this medication in their

locked cupboard.

Receipt of Controlled drugs

Action Rationale

1 Receipt of controlled drugs must be entered into a separate bound register of controlled drugs, which has numbered pages

2 Use a separate page for each drug and resident.





4. Storage of Medication in the Care home

Scope

This policy should cover the storage of all medication within the home. Details should be provided on the storage location and procedure, temperature monitoring, access to storage location and other aspect detailed below.

Action Rationale

1 Residents that are self administering are required to be provided with a personal lockable drawer/cupboard. Care workers should hold a duplicate key.

2 Where care workers are responsible for handling medication on behalf of residents, there must be a designated place for storing medication that is secure.

3 The storage area must be maintained at an acceptable temperature – less than 25˚C. This should be monitored and documented on a daily basis.

4 The decision of where to store medication must take into account the size of the home, nature of medication, sufficient to include nutritional supplements, dressings, stoma products, continence appliances etc

The size must be adequate to include

storage of new supplies immediately on

delivery, without obstructing safe access

to facilities.

5 All items must be stored off the floor.

6 If a medication cupboard is used – it must be of a suitable size and construction with a quality lock.

7 If a medication trolley is used, it must be lockable, constructed from suitable material and of a suitable size, appropriate to the needs of the home and fit for purposes of keeping the medication of each Resident separate.

The trolley must have sufficient capacity for all medication to be locked away in an interruption or an emergency during the medication administration round.

8 If a trolley is used to store medication, it must be locked and fixed to the wall when not used for medication administration or secured in the locked designated place.

9 The keys for the medication area, cupboard or trolley should not be part of the master system for the home.

Key security is essential to the security of

the medication, therefore, access should

be restricted to authorised members of

care workers only and the keys kept on

the person of that authorised member.

10 Subject to Home Office direction, the storage of controlled drugs (CD’s) where administration is undertaken by care workers should be in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973.

If CD’s are within the MDS then the whole box is subject to Misuse of Drugs (Safe Custody) Regulations. (See later guidance for storage of controlled drugs).

11 In the case of hazardous substances/medication, a Control of Substances Hazardous to Health Regulations (COSHH) assessment should be undertaken of medication that must be ‘handled’. Examples include external preparation such as steroids, cytotoxic medication such as methotrexate and hydroxyurea. (See Section 5




COSHH).

Storage of medication requiring refrigeration

Action Rationale

1. 1 For medication requiring refrigeration, a separate,

secure and dedicated refrigerator should be

available in the home to be used exclusively for the

storage of medication requiring cold storage.

For acute (one off) prescription items,

which may require refrigeration

storage, a dedicated shelf in the

domestic fridge may be appropriate –

provided that there is adequate

security to prevent any unauthorised

persons from reaching the medication

e.g. a lockable box placed within the

fridge.

2. 2 The temperature of the medication refrigerator

should be monitored daily when in use, using a

maximum/minimum thermometer and recorded

(maximum, minimum and actual temperature to be

recorded). Care workers should have a clear

understanding of what action to take if the

temperature is outside the normal range.

The normal range, usually between

2˚C and 8˚C, however the product

information leaflet should be checked

for confirmation. The community

pharmacy can also be contacted for

confirmation

3. 3 The refrigerator should be cleaned and defrosted

regularly. A record of defrosting should also be

kept.

BCUHB recommendation is a minimum

of once a month

4. 4 Care must be taken that the heat generated by the

refrigerator does not affect the room temperature, if

other medication is stored nearby/same room.

Notes:

1. The areas to prepare any medication must have solid, washable surfaces. There should be no ‘dust traps’.

2. There should be sufficient workspace with adequate lighting to facilitate the administration of medication.

3. Hand washing facilities should be in the same room or in the immediate vicinity of where the medication is

stored.

Controlled Drug Storage

Controlled drugs for residents who are not self administering must be stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973. This specifies the: Construction Method of fixing Lock and key for the cupboard

When a resident is self administrating their medication, they can hold their own individually dispensed supply of controlled drugs in their personal lockable cupboard.




5. Control of Substances Hazardous to Health Regulations (COSHH)

Scope

This guide covers all medication that may be harmful to health. Although all medications are generally exempt from COSHH regulations, certain medication if handled or accidentally ingested could prove hazardous to health.

Regulations require all employers to consider substances which might be hazardous to health in the

workplace. Any identified hazards must be assessed and steps must be taken to minimize the risk.

The hazard presented by a substance is its potential to cause harm, whereas the associated risk is the

likelihood that it will cause harm in the way it is actually used.

The Care home will follow the advice offered by the Community Pharmacist or Dispensing Doctor when a medication covered by this procedure is supplied to the home.

The Community Pharmacist or Dispensing Doctor supplying the medication to the Care Home must:

1. Identify any hazardous substances/medication supplied on a prescription to the Care Home prior to

supplying the Home.

2. Assess the risk to health from the way that substance is used in the Care Home and decide what

precautions are needed.

3. Advise on appropriate measures to control the risk to health and to minimize workers’ risks from

exposure to those substances.

4. Inform, instruct and train employees about the risks and the precautions to be taken.

5. Advice on the control measures to be used, and that any equipment provided for this purpose is properly

maintained and that procedures are followed.

6. Advise the Care Home of the procedure to undertake in the event of accidental ingestion or accidents.

Medication identified as a potential hazard to health includes:

Steroid creams e g Clobetasol , (Dermovate )

Cytotoxic creams e g Fluorouracil, (Efudix)

Cytotoxic medicines e g Methotrexate

Oxygen (See below)

Anabolic Steroids e.g. Finasteride, (Proscar).

Paraffin based skin products on Dressings and Clothing (See appendix 9)

The dispenser should highlight any medication covered by this procedure at every supply. If a new medication is supplied then the dispenser will provide the appropriate advice and ensure a risk assessment is undertaken.

When the Care Home receives advice and or training from the supplying dispenser on any medication under this procedure, the home must comply with any advice given. It is the homes responsibility to ensure that all care workers are aware of the risk assessment and what precaution they should take when handling the medication.

Any materials, equipment, written information required to comply with the advice must be provided by the employer.

Follow the link for guidance on cytotoxic drugs: www.hse.gov.uk/pubns/misc615.pdf

http://www.hse.gov.uk/pubns/misc615.pdf




6. Oxygen

Oxygen will be prescribed only after an assessment with a specialized oxygen assessment team, following a referral from a clinician e.g. GP, consultant, chest clinic etc.

The oxygen is supplied by an oxygen company, who will deliver and install all products needed. Oxygen

should be ordered directly from an oxygen supply company (as discussed with the GP Practice) via the Home Oxygen Order Form (HOOF). Regular orders will take up to three days, emergency orders within four hours

The oxygen supply company will determine the most appropriate oxygen delivery system for the resident

within the Care Home after a risk assessment. The Supplier is responsible for providing an oxygen delivery system that meets the clinical needs of the patient as set out on the order form by the clinician. It is also the supplier’s responsibility to ensure that the mode of oxygen delivery can be safely installed and used by the Resident.

The HOOF should not normally indicate a specific mode of delivery or item of oxygen equipment, although the clinician may indicate a requirement for a conserving device, specific nasal cannulae or mask, or a humidifier.

Oxygen is a fire hazard:

1. Never allow anyone to smoke when oxygen is being used.

2. Keep oxygen at least 6 feet away from heat or flames including gas heaters and cookers.

3. Never use flammable liquids such as paint thinner, cleaning fluids or aerosols whilst using oxygen.

4. Keep a fire extinguisher within easy reach.

5. Install fire alarms and smoke detectors and check they are working.

6. Never leave oxygen running when it is not being used.

7. Never place oxygen equipment near curtains, or cover it with clothes.

8. Never put the cannula or mask on the bed or chair whilst the oxygen is still running.

9. Keep internal doors open to help ventilate the room and prevent a buildup of gas.

http://www.homeoxygen.nhs.uk/1.php

http://www.homeoxygen.nhs.uk/1.php




7. Administration of medication

The responsibility for the safe administration lies with the Care Home Manager and trained and competent members of staff assigned to administer medicines. Medication must be administered in accordance with the prescriber’s instructions, and follow the manufactures information. It should not be administered for any other purpose or to any other resident.

The Care Home Manager should ensure that an up to date medication history is obtained and recorded for each new resident. This must be clearly documented in the care plan or equivalent.

Most establishments will identify specific times of day when the medication ‘round’ will be undertaken and this may follow the pattern of mealtimes. However, the time of administration must be carefully considered and respond to individual residents needs e.g. when medication is required in advance of food.

Action Rationale

1. At any given time the care worker must be able to identify the medication prescribed for each resident.

To minimise harm to resident

2. The care worker must be able to identify the resident to whom they are to administer the prescribed medication too.

Check the identity of the resident e.g. a recent photograph. Check the resident’s name and date of birth.

3. Administration may occur in several ways, e.g. individuals entering a clinical / medication room in turn, individual lockers in the resident’ room or by means of a trolley transported around the home.

4. Wash hands with bactericidal soap and water or bactericidal alcohol hand rub before and after each administration to a resident and ensure the work space is clean

To minimise the risk of cross infection

5. Consent must be obtained before administering medication

To ensure that the resident understands the procedure and gives their valid consent

6. Check the residents allergy status by asking them and checking care plan

To prevent any errors related to drug allergies

7. Ensure that you have the MAR or equivalent chart with you before you start administration. Check that the information contained on the MAR or equivalent chart is complete, correct and legible.

To protect the resident from harm

8. Select the required medication by checking the following against the MAR or equivalent chart:

Correct medicines name and dose

Check the expiry date

Correct date and time of administration

Correct route for administration

Medication has not already been administered

Take note of any recent changes in therapy.

If any of these pieces of information are missing, are unclear or illegible then the care worker should not

To ensure that the correct Resident is given the correct drug, in the prescribed dose, by the correct route, and to prevent any errors occurring

Treatment with medication that is

Scope

This Section covers all medication administered within the Care Home

Only trained and competent, designated members of staff can administer medication.

Our objective is the safe administration of medicines in a care home, with complete audit trail




proceed with administration and should consult with the residents GP or pharmacist.

outside the expiry date is dangerous. Medicines deteriorate with storage. The expiry date indicates when a particular medicine is no longer effective.

9. Empty the required dose into a medicine container (pot) Medication should be administered to the resident directly from the dispensed container, using the non touch technique

Medication should never be left out to be taken later

Medication should never be removed from the original container in which a pharmacist or dispensing doctor supplied it until the time of administration

To minimize the risk of cross‐infection.

To minimize the risk of harm to the care worker.

10. Liquid medication should be measured and administered using appropriate equipment. If an oral syringe is being used for administration, consent must be obtained.

11. Assist the resident to a comfortable position appropriate for medication administration that maintains the resident’s dignity.

12. Administer the medicine as prescribed

To meet legal requirements and local policy

13. Offer a glass of water (for oral medication), if allowed, assisting the Resident where necessary

14. Stay with the resident until administration process is complete.

To ensure that medication has been taken on time

15. Administration of medication should be recorded immediately. Record the dose given and sign the MAR or equivalent chart and care plan as per Section 6

To meet legal requirements and local policy

16. If medication is refused, the care worker should record the reason for non-administration on the back of the MAR or equivalent chart and in the care plan. If refusal of medication occurs for 2 days (48 hours) or more – the care worker needs to inform the resident’s Doctor to arrange a review of medication. Any refused or dropped medication must be disposed of in accordance with Section 10 – Disposal / Return of Medication.

17. ‘When required’ (PRN) medication must have adequate directions including the appropriate use of the medication e.g. to treat which symptoms, and the maximum daily dose and frequency. These details should also be in the care plan e.g. one or two tablets every four to six hours for relief of knee pain. No more than eight tablets in 24 hours. See Appendix 3 for further information.

Notes:

1. Medication should be administered strictly in accordance with the prescribers’ instructions; they cannot be

given for any other purpose or to any other resident. This also includes non-oral medication such as

dressings, creams and sip-feeds. The administration of non-prescribed medication must be risk assessed.

2. Administration should respond to the resident’s needs and allow for special provisions such as when

medication is required in advance of food or medication with specific dosage regimens.




3. Medication should never be potted up or passed to another care worker to administer to the resident at a

later time or date.

4. MAR or equivalent charts should be computer printed by the dispenser and not handwritten. Any medication

changes mid-month to the MAR or equivalent chart may be hand written in full exactly as written on the

dispensing label, unless a new MAR or equivalent chart is available. If possible, this hand written entry

should be checked and countersigned by a second member of staff. If this is not possible then the next care

worker to administer medication should check the record has been completed correctly and countersigned.

5. Where medication is administered from a monitored dosage systems (MDS) containing more than one type

of medication, the person administering the medication must be able to distinguish each individual

medication and as best practice explain each tablet to the individual, and be aware of any specific

instructions, e.g. before food. The use of this type of MDS systems is not recommended by Betsi Cadwaladr

University Health Board.

6. Special precautions apply to controlled drugs, creams, once weekly drugs and medicines covered by high

risk assessment and COSHH (please see Section 7a for guidance on administration of controlled drugs in

Residential Care Home’s)

7. Training and competence assessment for administration of medicines by carer worker must include the

following:

How to obtain consent.

How to check the identity of the resident e.g. a recent photograph

How to check the name, form, strength and dose of medication & how carer workers are able to

identify each medication when a single type of medication Monitored Dose System (MDS) is used.

How to cross check that the MAR or equivalent chart and the medication match

How to check if there have been any recent changes in therapy.

How to check the dose has not already been administered

How to check the route of administration, or if there are any special administration requirements.

How the Care worker administering medication records a variable dose.

How to clarify unclear dose instructions such as ‘as directed’.

How to deal with a medication administration error.

7a. Administration of controlled drugs

The administration of controlled drugs should be performed by two appropriately trained and competent

members of staff who perform the entire administration process. Ideally there should be two signatures on

the MAR or equivalent chart recording the administration.

1. The time of each administration of the drug must be entered and witnessed into the Controlled Drugs register, as well as on the MAR or equivalent chart.

2. The register must identify the balance remaining for each product separately for each resident.

3. The balance of controlled drugs must be checked at each administration and also on a regular basis. This is at the discretion of the nurse or manager in charge. Frequency of balance check should be daily, weekly or monthly depending on usage.

The register must be archived and retained for two years




8. Verbal orders or messages relating to medication or dosage changes

Action Rationale

1. Only under exceptional circumstances may care

workers accept verbal instructions for any

changes related to medicines use from the GP,

Pharmacist or Non medical prescriber. Verbal

instructions from anyone else are not

acceptable. The changes must be confirmed by

text or faxed or email where possible as soon as

possible.

2. When taking down the message it must be

repeated back to ensure that it is correct.

In order to ensure that messages are

relayed correctly.

3. All messages from the prescriber, relating to

medicines must be written onto the resident’s

care plan and daily diary.

Changes to medication must be written on the

MAR or equivalent chart, together with the date,

time and name of the authorising Health

Professional. The person completing the form

must sign and print their name on it and have

the change of medication checked by a second

person.

To ensure and provide continuity of care

and information

4. The Registered Manager should consult the GP

on any changes that will affect the care of the

service user, including reviewing the care plan if

necessary.

5. If the prescriber is present in the Care Home,

the prescriber must amend the MAR or

equivalent chart at the time of the visit

Scope

Only trained and competent, designated members of staff can receive a verbal order or messages

relating to mediation or dose change




9. Medication record keeping in Care Homes

Scope - There is a statutory requirement for the recording of all medication in care homes including the

ordering of medication, the receipt, administration and others.

The care home owner / manager will have the overall responsibility for the record keeping of medication

in care homes.

There is a statutory requirement for the recording of all medication in care homes, as detailed in the

respective Care Homes Regulations e.g. NSF for older people, National Minimum standards for Care

Homes for Older People (2004) Schedule3, The Care Homes (Wales) Regulations 2002

The standard of record keeping should ensure that records are properly completed, legible and current,

providing a complete audit trail of medication.

Records for administering repeat medication

Action Rationale

1 Any medicine administered and any doses refused should be immediately recorded on the MAR or equivalent chart.

Records should be kept for at least seven years in Adult services.

2 Records will be properly completed in indelible ink, legible and current providing a complete audit trail of all medication and the names of all care workers involved. Corrections or amendments made to MAR or equivalent charts must be clear. It is permissible to draw a line through the incorrect entry and re-write it. The original entry must not be obscured e.g. by using correction fluid.

3 When there is a choice of dosage e.g. 1-2 tablets, the number of tablets actually administered must be recorded.

4 If a handwritten MAR or equivalent chart is unavoidable, the care worker entering the information should sign the MAR or equivalent chart, and the next care worker to administer medication should check the record has been completed correctly and countersign.

Notes

1. The Medication Administration Record or equivalent chart (MAR) is the working document which should be

used to record all medication including non-prescription medication, sip feeds, creams etc.

2. The style or manner of MAR or equivalent chart is for the Care Home to determine, although the supplying

pharmacist or dispensing doctor may be able to support.

3. All new MAR or equivalent charts should be referenced back to the latest order for the repeat medication

and the previous MAR or equivalent chart

4. Care homes, which elect to store patient records on a computer, should take advice concerning the Data

Protection Act 1998.

5. Records should include homely remedies, medication on admission, medication supplied with hospital

discharge or outpatient visit.




Records to be made include:

Action Detail

1 Medication ordered See Section 2

The Care Home Manager should ensure that an up to date medication history is obtained and recorded for each new resident. This must be clearly documented in the care plan or equivalent.

2 Medication received See Section 3

All medication brought into a care home should be recorded with:

Date of receipt.

Name, strength and dosage.

Quantity.

Resident’s name.

Signature of member of care workers checking and recording.

At any given time the home must be able to identify the medication prescribed for each individual Resident.

On admission, written confirmation of the medication the resident is taking should be obtained. E g current repeat slip.

3 Medication administered (and any doses refused) See Section 6 .

Administration by Resident (Self- Administration)

A record should be maintained of the medication given to a self-administering Resident, including the date and signature of the responsible care worker.

Ordering and Receipt should be recorded when the home is involved in obtaining the medication.

Administration by Care workers The MAR or equivalent chart is the working document which should be used to record all medication administration.

4 Controlled Drugs See below & Section 8

5 Medication used away from the care home See Section 11

Appropriate entries are made in the home records to indicate the absence of resident and the details of the medication taken out of the home.

6 Medication transferred with the resident See Section 12

Include all quantities. Use Current MAR or equivalent chart. Store with service-user’s notes and not sent with the service-user.

7 Medication disposed of See Section 10

Following the death of a client all medication must be kept until no longer required by the coroner.

8 Medication Administration errors. See Section 11

9 Verbal orders. See Section 8

Notes:

A change in legislation means that care homes with nursing care can arrange for a licensed disposal

contractor to transport waste medication for disposal. This has been agreed by BCUHB. Or pharmacies can

(but are under no obligation to) accept waste from care home with nursing care although waste from these

sites are subject to stringent controls




9a. Controlled Drugs records

1. In addition to the records required in above, care homes must keep a separate record of receipt,

administration and disposal. These records must be kept in a bound book or register with numbered

pages.

2. The bound book will include the balance remaining for each product with a separate record page being

maintained for each Resident. It is recommended that the balance of controlled drugs be checked at each

administration and also on a regular basis e.g. weekly or monthly.

3. Entries must show

Date

Name of product received

The strength

The quantity

The form (i.e. tablet, liquid, capsule)




10. Disposal / Return of Medication

Care Home disposal or return of medication for residential care

Action Rationale

1 To provide a full audit trail of medication through

a care home, a record is required to identify the

removal from the home of a resident’s

medication.

2 The medications that are held in a care home at

any given time should be appropriate to the

current therapy of the resident, any surplus or

unwanted medication should be disposed of in

the appropriate manner.

When there is a change of therapy and a

product has been discontinued – the

medication should be returned to the

supplier (with the Resident’ consent).

3 When a resident chooses to leave the care

home, the medication should be returned to the

resident, unless they have consented to the safe

disposal of their medication.

Medication is the resident’s property.

4 All medication has an expiry date. Some expiry

dates are shortened when a product is in use e.g.

eye drops.

If a medication has a shorter expiry date

when it is in use, this will be detailed in

the patient information leaflet.

5 Following the death of a resident, the medication

should be retained for fourteen days, in case the

Coroner’s Office or courts required them.

6 The normal method for disposing of medication in

a care home should be by returning the

medication to the supplier.

The supplier can then ensure that the

medication is disposed of in the correct

manner

7 A complete record of medication leaving the care

home should be recorded.

8 The records should contain the following:-

Date of disposal/return to pharmacy

Name and strength of the medication

Quantity of medication

Name of resident to whom the medication

belonged.

Signature of the member of care workers who

arranged the return of the medication.

Reason for disposal e.g. stopped by GP,

patient deceased etc.

Liquid medication should be stored in its

original container in a locked cupboard,

separate from useable stock.

9 The community pharmacy must also counter-sign

these records to signify their acceptance of the

returned medication.

There needs to be a complete audit trail.

Note: A record is also necessary if medication is transferred to another care provider, including an NHS

hospital.

Scope - The procedure for the disposal / return of medication will differ between nursing and

residential care.




Care Home Disposal / Return for medication nursing care

Action Rationale

1. To provide a full audit trail of medication through a care home, a record is required to identify the removal from the care home of a resident’s medication.

2. The medications that are held in a care home at any given time should be appropriate to the current therapy of the resident, any surplus or unwanted medication should be disposed of in the appropriate manner.

When there is a change of therapy and a product has been discontinued– the medication should be destroyed (with the resident’ consent).

3. When a resident chooses to leave the care home, the medication should be returned to the Resident, unless the Resident has consented to the safe disposal of their medication.

4. All medication has an expiry date. Some expiry dates are shortened when a product is in use e.g., eye drops. (If a medication has a shorter expiry date when it is in use, this will be detailed in the patient information leaflet).

5. Following the death of resident, the medication should be retained for fourteen days, in case the Coroner’s Office or courts required them.

6. A record should be made, and a counter signature by the waste disposal collector to signify the collection

Waste transfer notes are required to be

kept for 2 years.

7. Medication must be removed from the original packaging before placing into the DOOP bin. Liquid medication should be stored in its original containers and stored in a locked cupboard until collection

8.

A complete record of medication going out of the home should be recorded. The records should contain the following:-

Name of resident to whom the medication belonged

Date of disposal



Signature of the member of care workers who arranged the disposal of medication plus an additional signature of a witness.

Reason for disposal e.g. stopped by GP, patient deceased etc.

Note:

A record is also necessary if medication is transferred to another care provider, including an NHS hospital.




Disposal/Return of Controlled Drugs

Action Rationale

1 Controlled drugs should be stored in the locked CD cupboard before denaturing or collection but segregated from useable stock.

2 Controlled drugs (CD’s), which have been obtained on individual NHS prescriptions, may be disposed of by returning to the supplying pharmacy. It is recommended that a signature of receipt be obtained from the pharmacist (or delivery driver accepting the return and the pharmacist).

3 Controlled drugs that are returned to the pharmacy for disposal should be separated from regular medication

4 A complete record of CD medication going out of the home should be recorded.





Name of Resident to whom the medication belonged.

Signature of the member of care workers who arranged the return of the medication and counter signature

Reason for disposal e.g. stopped by GP, patient deceased etc.

6 However, in the case of nursing home residents, the CD’s must be destroyed (i.e. by denaturing) in the presence of a witness and then must be collected with other waste by the waste collecting contractors.

For nursing homes opting to return

waste to the pharmacy please seek

advice from the receiving pharmacist.

Note: The disposal of a controlled drug must be entered in the register, witnessed and documented on the MAR or equivalent chart.




11. Medication Administration Error

Scope

It is important that an open culture exists in order to encourage immediate reporting of errors in the administration of medication.

Examples of administration errors are:

Wrong dose is given, too much, too little

Medication is not given

Medication is given to the wrong Resident.

Action Rationale

1 If a medication error occurs the carer worker must ensure the safety of the resident

2 For advice or information

Refer to product information leaflet.

Contact NHS direct (0845 4647) or local OOH service as appropriate.

3 It may be necessary to contact the GP / Pharmacist for immediate advice, information or assistance

To promote safe medicines management

4 The following must be informed of the incident:

Line manager / senior member of care workers

Manager/Proprietor of Care home

GP practice

Inform relative/guardian.

5 A record should be entered in the resident’s care plan/notes of the incident, and any occurrences which followed.

6 CSSIW must be informed of any incident (complete Medication Error Form / reg. 38 form available from link below

www.wales.nhs.uk/sitesplus/861/opendoc/176994

Reporting system

7 If an error is identified around prescribing or dispensing within either primary care or from the hospital then complete a significant event form and submit it to Primary Care Support Unit, Clinical Governance Department. http://howis.wales.nhs.uk/sitesplus/documents/861/BCUHB%20PCSU%20Incident%20Reporting%20form%20April%202016.pdf

For Conwy and Denbighshire /Central area

contact PCSU, Clinical Governance Department,

Mandy Casey ([email protected]

03000 856121)

For Flintshire and Wrexham/ East area contact:-

PCSU, Clinical Governance Department,

Richard Waterson

([email protected]

03000856670)

http://www.wales.nhs.uk/sitesplus/861/opendoc/176994

http://www.wales.nhs.uk/sitesplus/861/opendoc/176994








Notes

1. The care home must:

have a clear incident reporting system

Investigate reports and decide whether they need to offer training to an individual or review existing procedures

Record any action taken

Report serious incidents to the regulatory body 2. All care workers must be reminded of the importance of reporting all medication errors immediately,

regardless of however minor they appear to be. Not reporting an error may result in disciplinary action.

For Gwynedd and Anglesey/ West area contact

:-PCSU, Clinical Governance Department:- Mary

Cottrill Mary Cottrill ([email protected]

03000 852300)

8 A review or assessment of the administration procedure should be carried out, in order to assess why the error occurred and what steps can be taken to prevent the error from recurring.

Lesson learnt





12. Covert Administration of Medication

Scope It is essential to refer to “The North Wales standards of best of practice for medicines management in adults – section 22” on covert administration. The procedure below must align to the policy of the home on covert administration of medication. NB. All citizens have the right to refuse medication and this right should be respected.

Covert administration is when medicines are administered in a disguised format without the knowledge or consent of the person receiving them, for example in food or in a drink.

Covert administration can only occur where the resident has been assessed under the Mental Capacity Act

2005 as not having capacity to consent and there has been careful assessment of the citizen / resident’s

needs by a multi-disciplinary team.

When covert administration of medicines is being considered, there should be a 'best interests' meeting. The

purpose of this meeting is to agree whether administering medicines without the resident knowing (covertly) is

in the resident's best interests. A best interests meeting should be attended by care home staff, relevant

health professionals (including the prescriber and pharmacist) and a person who can communicate the views

and interests of the resident (this could be a family member, friend or independent mental capacity advocate

depending on the resident's previously stated wishes and individual circumstances). If the resident has an

attorney appointed under the Mental Capacity Act for health and welfare decisions, then this person should

be present at the meeting.

Action Rationale

1. A full risk assessment by the care home manager /

nurse should be made to assess capacity of the

resident to consent to receive medication.

A requirement of the Mental Capacity Act

2005.

2. The 'best interests' meeting agrees an appropriate

management plan for the resident including a date for

review.

The management plan would usually include:

a. medication review by the GP

b. medication review by the pharmacist to advise

the care home how the medication can be

covertly administered safely

c. clear documentation of the decision of the best

interests meeting

A written plan specific to the resident and

medication procedure for covert

administration of medication, must be

accessible for everyone involved in the

care of the resident and their

family/representatives

3. A plan to review the need for continued covert

administration of medicines on a regular basis must

be agreed and documented in the citizen / resident’s

care plan and recorded by the patient’s clinician within

their medical records.

An ad hoc review may be requested by the

care worker / citizen / resident

representative in the event of a change in

circumstance / condition of the citizen /

resident.

4. Specific instructions should be included by the

prescriber on the prescription as to the method of

covert administration.

To ensure the care worker understands

how to safely administer the medication.

5. The dispenser should include the instructions on the

dispensing label on the MAR or equivalent chart of

available, e.g. crush the medication and mix with

yogurt where compatible.

To ensure the care worker understands

how to safely administer the medication.




6. Alternative formulations of the medicine, that may be

more acceptable, must have been considered e.g.

liquid preparation

7. Administration of medication must follow the

procedure as set out in Section 7

To ensure safe administration

8. If there is no agreement to covert administration, then

there should be an immediate application to court.

Note:

1. The pharmacist must be involved in these decisions as adding medication to food or drink can alter its pharmacological properties and thereby affect its performance.

2. Regular attempts should continue to be made to encourage the resident to take the medication voluntarily

3. Not all medication can be crushed /dissolved. A reference list is available on http://www.newtguidelines.com/

4. The legal responsibility of the manufacturer ceases when the integrity of his product is breached i.e. when the tablet is crushed, broken or administered in a manner other than that in the Patient information leaflet.

5. Crushing medicines and mixing medicines with food or drink to make it more palatable or easier to

swallow is different to covert administration and residents must always be informed medication is being administered in food. When a resident has consented to this, it does not constitute covert administration but needs to be appropriately prescribed.

http://www.newtguidelines.com/




13. Use of medication away from the Care Home

Scope

This covers all situations where residents may require medication to take with them from the Care Home.

For example the resident is going on holiday, staying with relatives/friends etc...

Action Rationale

1 Care Workers must not fill compliance devices for resident

Secondary dispensing of medication into other containers, e.g. envelopes, empty bottles etc, is secondary dispensing and is illegal. There is the potential for drug error when medicines are prepared in advance into pots, even when a name is attached to the pot, this process has removed a vital safety net — to check the drug, strength and dose with the care home record and label on the medicine at the same time you check the identity of the person.

2 Medicines to be administered whilst the resident is away from home must be supplied in the original container. The instructions must be clear and followed accurately In some situations e.g. regular attendance at a day centre, a separate supply of medication can be organised for the period of leave and the remainder of the medication can stay in the home following discussion with the GP and community pharmacist.

Prevent the medications performance from being altered.

3 Entries need to be made onto the MAR or equivalent chart that the resident is away from home.

To ensure that duplicate doses are not

given

4 Details of the quantity of medication leaving and returned to the care home should be recorded

Note: If the person regularly goes to spend weekends with family, there is no reason why their medicines

should not go with them. The medicines are the person’s property

13a For regular Day Care away from the Care Home 1. If a resident regularly attends a day centre, school, college etc., steps must be taken to ensure that they

still receive their medication appropriately. 2. Ask the prescriber or pharmacist if the time of medication administration can be changed or amended to

cover the resident’s absence from the home. 3. The supplying pharmacist should be contacted for help and advice in dealing with the specific

circumstances. These may include: having a separate container of medicines specific to the time of day that the person takes regular leave, for example, lunch-time medicines for a person attending an adult training centre.

4. The records must clearly state what happens at that administration time, e.g. by the use of codes L = leave, etc.

5. The care workers will need to liaise with the day care setting to ensure that the medication is administered as intended for the resident and record in the resident’s care plan / daily diary.




14. Transfer of residents to another setting (e.g. Discharged from or Admitted to Hospital)

Scope

On occasion, residents will be either admitted to or discharged from hospital.

Admission to hospital:

Action Rationale

1. All current medication should be sent to hospital

with the resident.

2. Ensure that a photocopy of the most recent

MAR or equivalent chart is taken with the

resident to the hospital.

3. Ensure that any entries made on the reverse of the MAR or equivalent chart are also photocopied.

4. Under no circumstances must the original MAR or equivalent chart be sent with the resident, as this is a legal working document.

5. Entries must be made on the MAR or equivalent chart whilst the resident is in hospital, to indicate that the medication is not being administered in the care home

Resident discharged from hospital:-

Action Rationale

6. Residents discharged from hospital may have

medication that differs from that prior to

admission. The old (no longer in use) medication

must be disposed of as per Section 10. Normally,

residents will be discharged from hospital with a

minimum of 14 days’ supply of medication.

7. Ensure that the pink discharge sheet is brought

to the home as this will detail the only medication

the resident will be taking.

8. Any changes in medication must be documented immediately on the resident’s current MAR or equivalent chart

9. Inform the supplying pharmacy of all medication changes to the resident’s medication.

10. Send or take the discharge sheet to the resident’s GP surgery (within 48 hours)

11. Order any additional medication required




15. Homely Remedies

If the home does not allow the use of homely remedies then this should be documented.

Scope

At any given time the home should be able to identify the medication available as homely remedies, have

written approval from each GP for each remedy and have individual guidance in place for when a product

can be used and the dose to be given. The home should also have a record of when a resident has

received the remedy. The list of homely remedies that can be used has to be agreed in writing by each GP

practice stipulating if the guidance is for individual residents or for all residents registered with that practice.

Advice

1. Care homes can take advice from a GP prior to administering a Homely Remedy if preferred (e.g.

emergency doctor service at weekends)

2. Any medication must be administered in line with Section 7 of this document (Administration of

medicines)

3. Care workers who give homely remedies to residents are named and sign the process to confirm they

have the skills to administer the homely remedy and acknowledge that they will be accountable for their

action

4. Only packs purchased over-the-counter can be kept as Homely Remedies, these contain the appropriate

warnings and information.

5. The remedies must be stored separately from residents’ own medication, in a locked cupboard and must

be clearly marked HOMELY REMEDY

6. Ideally a separate book with a running balance and expiry dates of each Homely Remedy should also be

kept.

7. Expiry dates must be checked regularly and before use

8. Bottles of liquid should have the date marked on them when they are first opened. Product guidance (on

the pack) on how long to keep a bottle once opened should be followed.

9. Homes should maintain a record of the purchase and disposal of all homely remedies in order to provide

a full audit trail




Procedure

Developing a new Homely Remedy Policy

Each guidance should contain the following information:

Name, strength and form of medication.

Dosage and frequency of administration.

Specific dosage instructions

e.g. on an empty stomach

e.g. not to be taken at the same time as indigestion remedies’.

Criteria for use i.e. what conditions the remedy can be used for

e.g. for mouth ulcer

e.g. for occasional pain or headache.

Maximum duration of treatment before a GP should be contacted.

Any additional guidance that the home or GP wishes to include.

Agreement by GP, stating if the homely remedy is for all or individually named residents.

Action Rationale

1 The decision to administer a Homely Remedy or to contact the GP must only be made by an appropriately trained member of care workers.

2 When the authorised member of care workers is of the opinion that the resident requires a homely remedy they should:

Check the remedy is appropriate for the condition.

Check that there is written approval from the residents GP for the remedy to be used.

Check there are no interactions with other medication the resident is taking

3 All doses administered must be entered immediately on the back of the resident’s MAR and in the Homely remedies record book with the quantity, date and time and on the resident’s Care Plan, with details of the resident’s condition.

4 Doses may be repeated, according to the protocol for that remedy for a maximum duration of 48 hours unless otherwise instructed in the protocol.

If the resident does not respond to the Homely Remedy or if the condition worsens, refer to the GP or local community pharmacy even if this is before the maximum 48 hours period.




Example ONLY Homely Remedy Protocol

Only the medications listed and approved below may be used as Homely Remedies

Nursing/Care Home: ………………………………………………

To be used in conjunction with the homes medication policy

Homely Remedies List and Authorisation for Individual residents

Recording is best done on the same sheet as the record of administration of prescribed

medicines e.g. by using the back of the medication administration record sheet (MAR)

1. Paracetamol 500mg tablets or Paracetamol sugar-free liquid 250mg/5mL

Indications: Mild to moderate pain (headache, toothache or muscular), pyrexia Dose: One to Two tablets to be taken four to six hourly when required. Maximum dose of eight tablets (4g) in any 24 hour period, or 10-20 mL of the liquid up to four times a day leaving at least four hours between doses (maximum of 80mL in any 24 hour period Cautions: (See current BNF for other cautions)

Be aware of any preparations they may already be taking that contain paracetamol

2. Gaviscon/Peptac Suspension

Indications: Dyspepsia Dose: 10 to 20mL after meals and at night (maximum of 40mL in any 24 hour period) Cautions: (See current BNF for other cautions)

May affect absorption of enteric coated tablets

Do not give within two hours of giving other drugs as it may affect absorption.

Do not give to residents with heart failure or those on a low salt diet because it has high sodium content.

3. Lactulose

Indications: Constipation Dose: 10-15mL twice daily (maximum dose of 30mL in any 24 hour period) Cautions: (see current BNF for other cautions)

May take up to 48 hours to work.

Can cause wind.

4. Rehydrate sachets

Indications: Mild Diarrhoea (not more than 3 loose stools in 24 hours)




Dose: One sachet after each loose motion, in addition to normal fluid intake.(maximum of 5 sachets in any 24 hour period) Cautions: (See current BNF for other cautions) USE FOR A MAXIMUM OF 12 HOURS BEFORE CONSULTING GP

Do not give without first consulting GP if resident is obviously suffering or diarrhoea is moderate or severe.

Do not give without first consulting GP if more than one resident is affected

Do not give without first consulting GP if resident is diabetic

5. Senna Tablets or Senokot Syrup

Indications: Constipation Dose: One to two tablets or 5mL to 10mL at night (maximum of 2 tablets or 10mL in any 24 hour period) Cautions: (See current BNF for other cautions)

May colour the urine or stools

6. Simple Linctus sugar free

Indications: Dry irritating cough Dose: 5mL to be taken three to four times daily (maximum dose of 20mL in any 24 hour period) Cautions:

Can be given to diabetics

The above list of medication are authorised to be given as a homely remedy to the named resident’s listed overleaf Name of Doctor: …………………………………. Name and Address of GP Practice: Signature of Doctor …………………………………………………… Date………………… Review Date……………………………

Name of care workers qualified to administer Signature Date




Residents Name Date of Birth

Medication excluded for list overleaf (if any) and reason for exclusion.

Medication Reason

Example; Mr. John Smith 12/12/1912 2

Resident has heart failure

4 Resident is diabetic




16 Controlled drugs administration in Care Home

Scope

This policy incorporates additional standards for the storage, administration and recording of Controlled Drugs. The Misuse of Drugs Act 1971 is the legislation governing Controlled Drugs.

Controlled Drug Storage

Controlled drugs for residents who are not self administration must be stored in cupboards meeting the requirements of the Misuse of Drugs (Safe Custody) Regulation 1973. This specifies the:

Construction

Method of fixing

Lock and key for the cupboard When a resident is self administration they can hold their own individually dispensed supply of controlled drugs in their personal lockable cupboard.

Administration

Objective

Safe administration of medicines (Controlled Drugs) in a care home with full audit trail complying with CD regulations and law

Responsibility

Care Home Manager and trained and competent members of staff / care workers assigned to administer medicines and certified as competent .This is recognised as being a high risk operation and as such is always undertaken by 2 designated members of staff / care workers

What? How?

1 Locate of medication Controlled drugs are stored in a locked cabinet within the locked controlled drugs cupboard within secure a medication room. The keys to both cupboards are held by responsible officer on the shift.

2 Locate Controlled Drug Register A controlled drug bound register of an approved pattern and has numbered pages is required. Each Resident is to have a separate page for every individual drug Each administration of the drug must be entered into this register Each disposal of the drug must be entered into the register The register must identify the balance remaining of each drug Frequency of balance check should be daily, weekly or monthly depending on usage. This is at the discretion of the nurse or manager in charge.

3 Ascertain if the resident has any allergies to the prescribed medication or has experienced any “side effects”

This could by personal observation , verbal communication or direct questioning E.g. hand over

4 Check that the medication has not already been administered




5 Identify the right medicine for the resident

Both designated persons should identify the right medicine from the controlled drug cupboard

6 Identify the right formulation and route

Controlled drugs can be as tablets, capsules, patches, liquids or suppositories

7 Check the expiry date of the original pack

8 Identify the correct dose E.g. If it is a "when required medicine " does the Resident require the dose?

9 Consider if any of the warnings or special precautions or instructions are to be considered

E.g. Does the medicine have to be given before food, after food or with food? Does the medicine have to be dispersed in water? Is the medicine to be swallowed whole, or not crushed?

10 Administration of controlled drug Dispense the medication into appropriate pot/receptacle Check that the controlled drug corresponds with MAR or equivalent chart. i.e. - resident’s name, dosage, quantity and time With 2 care workers present count amount of controlled drug in appropriate packaging/venalink. Check amount against what is written in controlled drugs register to ensure balance is correct

11 Offer the resident a glass of water to assists in the swallowing of medicine if applicable

Some tablets are dispersed in water before swallowing

12 Hand the medicine to the resident via a receptacle.

This receptacle should always be handed to the Resident and not left on a table or other object. Secondary dispensing is not allowed.

13 Observe the resident taking the medicine, allowing as much dignity and privacy as possible

You must be clear that that the medicine has been taken but cannot force any patient to take any medicine, the residents choice is paramount

14 Accurately record the administration of the medicine onto the Medicine Administration Record (MAR) and the CD register before you leave the resident.

2 members of care workers to go to the resident taking medication, MAR or equivalent chart and Controlled drug register Remember if it’s not recorded, according to law it has not happened!

15 Second signature to confirm administration of medicine on MAR or equivalent chart and in CD register

Any controlled drug administration is to be observed and documented by two persons

16 Check the running balance of the controlled drug medicines in the register and both designated persons to countersign if correct

Ensure medication is locked away immediately following administration

17 A record must be made of any instances of non-administration or refusal and the reason for non-administration documented in the residents care plan

18 If an error in the running balance is detected, inform Registered manager or other designated person immediately e.g. Assistant Manager responsible cover or Area Manager




Controlled Drugs Records

1. In addition to the records required in Section 9a, care homes must keep a separate record of receipt, administration and disposal. These records must be kept in a bound book or register with numbered pages.

2. The bound book will include the balance remaining for each product with a separate record page being

maintained for each resident. It is recommended that the balance of controlled drugs be checked at each administration and also on a regular basis. This is at the discretion of the nurse or manager in charge. Frequency of balance check should be daily, weekly or monthly depending on usage.

3. Entries must show

Date

Name of product received

The strength

The quantity

The form (i.e. tablet, liquid, capsule)

Disposal/Return of Controlled Drugs

What? How?

1 Controlled Drugs should be stored in the locked CD cupboard before denaturing or collection but segregated from useable stock.

2 Controlled drugs (CD’s), which have been obtained on individual NHS prescriptions, may be disposed of by returning to the supplying pharmacy. It is recommended that a signature of receipt be obtained from the pharmacist (or delivery driver accepting the return and the pharmacist).

3 Controlled drugs that are returned to the pharmacy for disposal should be separated from regular medication

4 A complete record of CD medication going out of the home should be recorded.





Name of resident to whom the medication belonged.

Signature of the member of care workers who arranged the return of the medication and counter signature

Reason for disposal i.e. stopped by GP, patient deceased etc.

6 However, in the case of nursing home patients, the CD’s must be destroyed (i.e. by denaturing) in the presence of a witness and then must be collected with other waste by the waste collecting contractors.

For nursing homes opting to return waste to the pharmacy please seek advice from the receiving pharmacist.




17 ‘When required’ medication (PRN medication) are administered Key Point

Medication prescribed to be taken ‘when required’ (PRN) is usually prescribed to treat short term or

intermittent medical conditions or symptoms i.e. it is not to be taken regularly

The Care Plan should have clear instructions describing whether the medication should be offered to the

resident at regular intervals, or if it should only be given in response to a request from the resident.

What? How?

1 To ensure the medication is given as intended, a specific plan for administration must be recorded in the care plan and ideally kept with the MAR or equivalent chart

The care worker must ensure that there are specific instructions on the MAR or equivalent chart, such as:

What the medication is being used for e.g. for relief of knee pain, to aid sleep

The minimum interval between doses

The quantity/dose of medication to be given

The maximum number of doses in 24 hours

Care workers are not permitted to

assist with ‘when required

medication’ unless there are

specific instructions which provide

details for use

The resident should be offered the medication at the times they are experiencing the symptom either by telling the care worker, or by the care worker identifying the residents need as outlined in the care plan

2 Before administration of any prescribed medication the care worker must look at the residents MAR or equivalent chart and check and follow the procedure described in Section 7

The care worker should:

Check when the last dose was given

Check that the minimum interval between doses has passed.

Check that the resident has not taken a dose themselves if they are self administering, or had a dose administered by another care worker.

Record the exact time, date and dose of medication administered.

To prevent any errors occurring

To maintain contemporaneous records keeping ( see Section 9 Medication Record Keeping)

3 If ‘when required medication’ is administered infrequently, check that the medication was prescribed for the purpose for which it is now required, that it has not been replaced by a different ‘PRN’ or regular medication, and that the resident has not started any new medication which could interact.

Consideration should be given to the residents capacity

to refuse the medication

A record does not have to be made

at each visit to show that the

resident has been offered the

medication but it is good practice to

do this and to indicate when the

PRN medication is refused

4 Care workers should inform their manager/person in charge, who should contact the residents doctor if:

The resident wishes to take PRN medication more frequently than prescribed

Use of the PRN medication increases

If there is reason to believe the PRN is no longer effective

If there is reason to believe the PRN is no longer




required

5 It is good practice to record the balance of PRNs after each dose is administered

PRN that is still in use & in date

should be carried over from one

month to the next & not disposed of

to avoid waste

6 Record the administration on the MAR or equivalent charts and document in the residents care plan

To maintain accurate records (see Section 9 Medication Record Keeping) and provide a point of reference in the event of any queries and prevent any duplication of treatment




Members of the original Working Group:

Name Title

Susan Murphy Assistant Director of Pharmacy and Medicines Management (west)

Eiriann Turner Medicines Management Specialist Nurse

Val Bamber Medicines Management Specialist Nurse

Hayley Jones Medicines Management Specialist Nurse

Sarah Felicello Pharmacist P&MM

Sue Randles Pharmacy Technician

Members of the review group December 2016

Consultation/Engagement has taken place with:

Name of organisational group

Date

Approved

yes/no

Comments

Clinic advisory group April 2020 yes No comments

Medicines Policy Procedure and PGD group May 2020 yes No comments

Drugs and Therapeutics group May 2020 yes No comments

Name Title

Alan Hughes Medicines Governance Lead Pharmacist – Chair

William Duffield Lead Pharmacist, Patient Safety

Chris Thomas Specialist Nurse, Pharmacy & Medicines Management

Katherine White Specialist Nurse, Pharmacy & Medicines Management

Jonathan Sutton Consultant Gastroenterologist

Alison Cox Prescribing Information Support Pharmacist