Medication Policy

Care Homes for Older People


This policy and `Good Practice Guidelines for the safe administration of medicines' was agreed by the Directorate and forms part of the overall departmental "Stay Safe at Work" Health and Safety Policies and Procedures.

This Management of Medication Policy is the result of work carried out by the Medication Review Working Group and replaces the "Management of Medication", Residential Elderly and Day Care Services (February 2002).

The policy has been produced with the assistance of Social Services Managers, Practitioners, and staff from Prime Care Trusts.

Consultation process on the revised policy:

The County Council is committed to this policy which will be subject to a rigorous periodic and systematic review, the first review will be undertaken on: 1st September 2007.

1. Policy Statement

2. Aims & Objectives

3. The Guidelines

4. General Principals of Good Practice

4.1 Registered managers must establish safe working systems for all aspects of

4.2 Medicines and the arrangement for its management and administration should

remain confidential.

4.3 Medicines will be administered in a way, which respects the individual rights, dignity, privacy, cultural and religious beliefs of the service user.

4.4 Information should only be shared on a need to know basis and, whenever

possible, with the informed consent of service users and their


4.5 The department believes that every service user has a right to manage and

4.5.1 Responsibility for the administration of medicines will only be taken with the full knowledge and consent of the service user wherever possible. Full consideration of an individual's ability to take their medicines will be determined by a comprehensive risk assessment.

4.5.2 The department also understands that despite the best effort of staff to sensitively obtain consent, there are circumstances where service users

4.5.3. In such situations it is accepted that administration of medicines without consent may be necessary where the service users Registered Practitioner advises that the medicines are in their best interest for example: Mental Health Legislation.

4.6 Where Service Users can make a decision, refusal of treatment should be respected (See section 11 on Refusal and Covert Administration).

4.7 Medicines will only be managed in accordance with an individuals care plan, Medicines Administration Record (MAR) chart, medication profile and a comprehensive risk assessment, which must be reviewed and updated as required on an individual bases, or annual as a minimum.

4.8 Medicines prescribed for the use of one service user must not be administered to anyone else; this also applies to wound dressing, nutritional supplements, surgical sundries etc.

4.9 As a source of reference, every home must have an up to date edition (not more than 18 months old) of the British National Formulary (BNF).

5. Service Users Medicines on admission to a Care Home setting

5.1 Roles and Responsibilities

5.1.1 Consult with prospective service users to establish if medicines are currently being taken, and to discuss the arrangements for on-going management of medicines.

5.1.2 Gather as much relevant information as possible about their medication needs by obtaining permission to consult with appropriate others (GP, Carer, Family etc).

5.1.3 Provide a care plan and Form M1, which specifies clearly the support service users require with their medicines.

5.1.4 On admission the care staff at the home must be provided with:

5.1.5 Following an emergency admission, either during the day or out of office hours into a care home, assessment staff/standby officers must establish what immediate action, if any, needs to be taken in respect of medicines e.g. Arrange a GP visit, collection of medicines from the service user's home.

5.1.6 Assessment staff/care coordinators are central to ensuring that service users on admission receive the appropriate level of assistance they require with administration of medicines.

5.1.7 The department reserves the right to postpone admission if medication or information received is insufficient.

5.2 Care Home Staff on admission must:

5.2.1 Ensure the appropriate documentation has been received from the assessment staff which includes Form M1 and Care Plan.

5.2.2 After consideration of the care assessment documentation, an initial risk assessment of the service users ability to self medicate must be undertaken and whatever the outcome a record must be made on the appropriate forms.

5.2.3 When the medicines are not received in a SMDS, arrangements must be made for the prescription to be sent to the local community pharmacist supplying the home to be dispensed if possible into a SMDS and ensure receipt of a printed MAR chart.

5.2.4 In an emergency, when deemed necessary, it is the responsibility of the Manager/Senior Support Worker (SSW) to confirm the service users current prescribed medicines with the Registered Practitioner (Form M2), and to organise the medicines to be administered from the service users own supply as directed on the container labels.

5.2.5 The current prescribed medicines must be entered onto Form M9 by the Manager/SSW clearly copying the exact prescription label, NO abbreviations to be used. The entries must be checked and signed immediately by a second competent person and must be printed in black ink for clarity.

5.2.6 Arrangements are then to be made within 72 hours by the Manager/SSW to

5.2.7 For evening admission after surgery hours, medicines should be withheld until confirmation can be obtained the following morning. If there are immediate concerns with the service users health, the out-of-hours GP service must be contacted.

5.2.8 Ensure that the service users medication regime is documented on the individual care plan, medication profile and daily report form.

6. Administration by Staff

6.1 Where service users require assistance to manage their medicines, the

current good practice of administering from a sealed monitored dosage

system (SMDS), where medicines are compatible with this method, must


6.2 The medicines trolley should be taken to individual service users and all

medicines should be administered directly from the containers or SMDS,

which will bear the name of individual service user, name and dosage of drug,

directions for administration and dispensing date.

6.2.1 To ensure the hygienically handling of medicines, they should be placed

directly from the SMDS into a small medicine pot immediately before


6.3 It is essential that before administration, the person who administers the

medicine refers to the MAR chart and checks the details of all medicines due

discrepancies noted must be addressed and documented on Form M6 error of

medication administration form.

6.3.1 After the medication has been administered the MAR chart must be signed

immediately in black ink.

6.3.2 There must be evidence to show that the MAR charts are checked weekly for

errors and compliance by the Manager/SSW. e.g. medicines that have been

administered are not signed for.

6.4 For the administration of topical medicines (creams, ointments and lotions). Follow the instructions carefully as directed on the medicine label and on the Service User's Form M12 body chart, and record and sign immediately in black ink on the MAR chart, that the treatment/medicine has been given.

6.5 If an emergency arises that requires the attention of the Manager/SSW whilst they are administering medicines, then the trolley must be locked and secured until they are able to return.

6.6 The home must retain a list of staff members authorised to administer medicines, which includes a record of their approved initials in the front of the Medicines Administration File, also to include date of recent competency and that staff have read, understood and will adhere to the policy.

6.7 All MAR charts must be retained in individual service users file for a minimum of three years from the date of last entry, and should be retrievable if needed.

7. New, discontinued or change in dosage of Medicines

7.1 The Registered Practitioner should ideally have the MAR chart, medication profile and the record of medicines taken, including homely remedies, accessible at the time of a visit, to enable changes to be made directly, to ease communication links and smooth the process of generating future prescriptions.

7.2 Although it is not part of the contract for the Registered Practitioner to sign the MAR chart or medication profile, it would be considered an element of good practice, particularly for changes to doses or discontinuation of medicines.

7.3 All changes must be authorised in writing by a Registered Practitioner. It may

be necessary in some instances to follow a verbal instruction, in these

as it is given on the Form M3 and then repeat it back. The form must then be

faxed as soon as practicable to the Registered Practitioner to confirm the


7.3.1 After notification of the change to the dosage of the medicine, the Manager or

SSW should amend the MAR chart, medication profile and record the

change in the clients daily report form. The amendments or new entries,

especially when a new prescription starts half way through the month must

be entered onto the MAR Chart or Form M9 by a Manager/SSW clearly

copying the exact prescription label, NO abbreviations to be used. The

entries must be checked and signed immediately by a second competent

person. All entries must be printed in black ink for clarity.

7.3.2 In addition, the community pharmacist should be immediately notified either by fax or telephone of any changes, in order that the service user's records remain up to date and that the next printed MAR chart supplied is correct.

7.3.3 If the relevant medicine is supplied in an SMDS, then this, together with the MAR chart, must be returned to the community pharmacist promptly for amendment.

7.4 At no time, accept a telephone instruction from a Registered Practitioner to give one service user another's medicine. Should a Registered Practitioner request this, explain that you are not allowed to do this and insist on a visit. In the event a visit is declined, inform him/her you will only continue to administer medicines as per MAR chart, and if service user's condition necessitates medical attention, then in the absence of a visit, emergency services will be summoned.

8. Prescribed "as required" (PRN) Medicines

8.1 All forms of PRN medicines must be prescribed and administered as directed

8.1.1 When a variable PRN dose is prescribed, then the number of doses (tablets,

or capsules) given should be recorded on the MAR chart each time.

8.1.2 The Registered Practitioner should be requested to indicate how often a PRN dose can be given, and the maximum number of times the dose can be given in 24 hours.

8.1.3 Staff must record in the service users daily record the circumstances that lead to the medicine being administered, dose and time given and whether the desired outcome was achieved. If the desired outcome was not achieved, then it must also be documented in the service user's daily record, and the registered practitioner contacted to review the medicine.

8.1.4. When "as required" (PRN) medicine is repeatedly requested, the service

user's Registered Practitioner must be contacted to initiate a medication


9. Authorised (NON-Prescribed) PRN Paracetamol

9.1 Care Home staff will only administer non-prescribed PRN paracetamol at the service users request if:

10. Arrangements for Service Users who self medicate

10.1 Once a risk assessment has been completed Service users should be encouraged to be responsible for their own medicines in accordance with the MAR chart and medication profile.

10.2 This will preserve independence and prepare those in short term care for their

return to the community, where they will need to look after their own


10.3 Service Users must be provided with a personal lockable drawer or cupboard where medicines can be safely stored. Wherever appropriate, service users should be strongly encouraged to use a sealed monitored dosage system (SMDS).

10.4 Permission must be sought from service users to enable care staff to have access to monitor and review medicines.

10.5 The assessment of service user's capacity to self-medicate will be reviewed at least annually and any significant changes will necessitate a review sooner as identified on the risk assessment.

10.6 Where a service user is assessed as no longer having capacity, the registered manager will sensitively consult with the service user and, where appropriate, a family member in a multidisciplinary team meeting to discuss assuming responsibility for administering medicines.

10.7 All service users who insist upon self-medicating, despite the advice of the home and their GP, should be asked to sign a disclaimer (form M11). Their cases should be discussed with their GP/nurse/keyworker and a plan of regular reviews set in place.

10.8 The practice of carrying medicines in handbags or pockets should be actively discouraged, except where medical advice recommends they be available at all times e.g. In the case of angina tablets, or spray/inhalers for breathlessness. Where service users refuse to adhere to the advice, a note of this must be recorded on their individual care plans.

11. Refusal and Covert Administration

11.1 An adult who has mental capacity has the legal right to refuse treatments, even if a refusal will adversely affect their health or shorten their life.

11.2 When a service user has mental capacity, staff must respect a service user's refusal to take medicines. Failure to do so is unlawful in both civil and criminal law, and is a breach of the service user's human rights. The exception to this principal, concerns treatment under relevant mental health legislation.

11.3 If a service user refuses to take prescribed medicines then the reason for the refusal must be recorded on the back of the MAR chart and the service user's daily report form. Staff must then refer to the Doctor's Statement (form M1) and follow the GP's instructions.

11.4 Information recorded can then be discussed as part of a medication review with the service user's Registered Practitioner/community pharmacist.

11.5 Service users must be presumed to have the mental capacity to consent or, refuse to take medication unless they:

11.6 Where a service user is considered to lack the capacity to give consent or, their wishes appear to be contrary to their best interests, then the Registered Practitioner responsible for his/her treatment should be consulted.

11.7 The assessment of capacity is primarily the decision of the service users Registered Practitioner, but relatives and/or care staff should be involved in discussions about this assessment. No one, not even a spouse can consent for another adult, but the views of family and close friends may be helpful in clarifying a service users wishes and establishing their best interests.

11.8 Covert administration of medicines must only be used in the case of service users who actively refuse their medicines, but who are judged not to have the capacity to understand the consequences of their refusal.

11.9 Any decisions to administer medicines covertly, must take into account the following considerations based on the UKCC (NMC) Guidelines:

11.9.1The best interests of the service user must be considered at all times.

11.9.2 The medication must be considered essential for the service user's health and wellbeing, or for the safety of others.

11.9.3 The decision to administer medicines covertly should not be considered routine and must be reached only after an assessment of the service user's care needs and a multi-disciplinary meeting including carers, relatives, health professionals and advocates as appropriate.

11.9.4 It should be done on an individual basis in order to avoid routine administration of medicines in this way.

11.9.5 The method of administering medicines covertly should firstly be agreed with the community pharmacist, alternative formulations of the medicine that may be more acceptable should be considered e.g. liquid preparation. A medicine should only be crushed when it has been shown not to alter the pharmaceutical properties.

11.9.6 The decision and the action taken, including the names of all parties concerned, should be documented in the service user's care plan/risk assessment and reviewed at agreed intervals.

11.9.7 Regular attempts should be made to encourage the service user to take their medicines; this should be documented in a daily report form. With some service users this might be helped by giving regular information, explanation and encouragement by a key worker, who has a good rapport with the service user.

11.9.8 Medicines should never be administered in a covert way merely for the

convenience of staff at the home. Any abuse of the procedure will be viewed

as a serious disciplinary matter.

11.10 Under no circumstances should service users be forced to take medicines

12. Arrangements for Service Users away from the Care Home

12.1 Service users will at times need medicines away from their care home. Where possible the original dispensed supply should accompany the service user.

12.2 Where this is not practicable, and whenever possible two authorised staff must prepare the medicines for someone else to administer, and sign on the back of the MAR chart that they have done so.

12.3 The medicines must be placed in appropriate containers and must be labelled to show:

12.4 Upon return to the care home, staff who were responsible for administering

user's individual daily report form and MAR chart.

12.5 In the event of an emergency evacuation of the care home please refer to:

Service users' medication, in the event of an emergency evacuation

of the care home.

13. Controlled Drugs

13.1 Two staff are required to record in a controlled drugs register when receiving, administering, and returning the controlled drugs to the pharmacy.

13.2 All entries should be dated, signed, timed and witnessed, and the balance should be checked at each administration.

13.3 There must be evidence to show that the controlled drugs balance is checked on a weekly basis by either the Manager/SSW.

13.4 Safe storage of controlled drugs - See section 18, Security & Storage of


14. Reviews

14.1 Manager/SSW to ensure in conjunction with the Registered Practitioner agreement on the frequency of a medication review, but generally a minimum annual review is recommended.

14.2 Side effects from medicines need to be monitored, and Care Staff must alert Manager/SSW if a service users condition changes. There is a need to be especially alert when the Registered Practitioner prescribes new, or alters a service users medicine. The Manager/SSW will immediately consult the service users Registered Practitioner for advice if they have any concerns and notify the next of kin of all changes and any action taken.

15. Pharmaceutical Services

15.1 National Minimum Standards for Care Homes for Older People, Standard 17:


15.3 Practice Review

15.3.1 Changes in legislation have prompted a review of the current practice guidance, with one aim being to develop a platform of joint working with Local Authorities and care homes.

15.3.2 Managers and care staff must continue to work closely together with the local community pharmacist to provide advice and help to the service users within our care homes.

16. Management of Medication errors and incidents.

16.1 The department recognises that, despite the high standards of good practice, mistakes may occasionally happen. It is important that an open culture exists in order to encourage their immediate reporting.

16.2 Every employee has a duty and responsibility to report any errors/incidents to his/her line manager, and refer to and complete Form M6.

16.3 Errors/incidents should be dealt with in a constructive manner that addresses the underlying reasons and procedures reviewed in order to prevent reoccurrence.

16.4 If error was found to be caused by reckless practice and concealed, a thorough and careful investigation will be undertaken in accordance with the County Council's Disciplinary Procedures.

17. Receipt and Ordering of Medicines:

17.1 The Manager/SSW must record all medicines brought into the home from

whatever source, including:

The record should show:

17.2 Ordering

17.2.1 Repeat Prescriptions

17.2.2 Stock to be checked for items required (remembering service user's who self medicate) to ensure adequate supplies are maintained.

17.2.3 Prescriptions are for a maximum of 28 days.

17.2.4 Using repeat prescription print out from Registered Practitioner, indicate required medicines by referring to service users individual profile and MAR chart.

17.2.5 Check for discontinued medicines and remove from list.

17.2.6 Check for new medicines and add to list if not shown.

17.2.7 Photocopy prescription requests before forwarding to surgeries.

17.2.8 It is also the responsibility of the Manager/SSW (prior to the prescription being submitted to the pharmacy for dispensing) to sign the exemption declaration on the back of the prescription form on behalf of the service user, if the service user is unable to do this themselves.

17.2.9 The Manager/SSW should photocopy prescription requests before forwarding them to the GP surgeries. These should be retained in the Service Users file to serve as:

17.2.10 When prescriptions are returned from the surgeries, they must be checked for accuracy, prior to forwarding to local community pharmacist. If discrepancies are found, prescriptions are to be returned to Registered Practitioner for amendments.

17.2.11 If items are required at other times, a written request must be sent to the Registered Practitioner using Form M7 and a copy to be kept on file.

17.3 Medicines received from Pharmacy

17.3.1 The Manager/SSW has responsibility to check all medicines on receipt from

pharmacy, against record of ordered medicines and record on the

appropriate documentation.

17.3.2 Discrepancies must be noted and local community pharmacist notified.

17.3.3 Where medicines for a service user differ unexpectedly from those received for the same service user in the past, the Manager/SSW should check with the community pharmacist or Registered Practitioner before administering the medicine.

17.3.4 Check and replace previous month's MAR chart, and retain in service users file.

17.3.5 Protocol for temporary managers:

18. Security and Storage of Medicines

18.1 Medicines must be stored in a dedicated locked medicines room which must have sufficient space to store nutritional supplements, prescribed dressings, surgical sundries etc.

18.2 Medicines, which are for internal use, should be separate from those for external use.

18.3. Care must be taken to ensure that medical items are stored off the floor at all

18.4 Medicines must be stored away from any source of heat, moisture or direct


18.5 Good practice recommends storage being kept below 25ºC. Daily temperature checks should be made and a record of these kept in the medication room. If a temperature check is found to be above 25ºC then it must be reported immediately via the Property Help Desk for immediate repair.

18.6 Stock levels of medicines for each service user are to be kept at an appropriate level, and dependant upon need. Expiry dates should be checked and monitored monthly. Any stock that has expired should immediately removed from use and disposed of as point 19.

18.7 Medicines requiring refrigeration should be stored in a locked drug fridge.

18.8 Daily monitoring and recording of the fridge temperature (normal range

should be between 2ºC and 8ºC) must be undertaken using a

maximum/minimum thermometer. The thermometer must be reset after each

daily reading to ensure that the temperature hasn't risen or fallen outside the

required range since the last reading. If the temperature reading is outside

the normal range it must be reported immediately to property maintenance

for service/repair. All affected medicines will have to be replaced

immediately. Spoilt stock must be returned to Pharmacy and a record of the

returns kept.

18.8.1 The drug fridge must be cleaned and defrosted regularly.

18.9 Medicines supplied in a SMDS are to be stored in a medicine trolley, and

when not in use, the trolley must be secured to a wall or kept in the medicine


18.10 Keys for the medicines room, controlled drugs cupboard and trolley must not

be part of the master system for the home.

18.11 Key security is integral to security of the medicines. Therefore, access must

be restricted to authorised members of staff only (Manager/SSW). Keys

must be kept on the person in charge and handed over to the authorised

person in charge at each shift change.

In the event of an emergency a duplicate set of keys must be kept in the

Care Homes Office Safe. An incident form should be submitted for each

occasion that the drug keys are lost and the situation requires the duplicate

set to be used.

18.12 A metal cupboard must be secured to the wall in the medicines room for the

safe storage of controlled drugs, that complies with the Misuse of Drugs (Safe

Custody) Regulation 1973.

18.13 The medicines room and trolley must be kept clean and tidy at all times.

18.14 Hand washing facilities must be provided in the room.

19. Disposal of Medicines

19.1 To provide a full audit trail of all medicines through a care home, a record is required, to identify the removal from the home of a service user's medicines. This record should detail the following:

19.2 This record is also necessary when medicines are transferred to another care provider, including an NHS hospital.

19.3 Medicines should be disposed of when:

19.4 Where service users are self-administering insulin, or any other medicines with a syringe, a "sharps box" must be provided by the Community Nurse and stored safely in the locked medication room.

20. Over the Counter (OTC) Medicines (Homely Remedies)

20.1 OTC/Homely remedies can be purchased for the individual service user on their request, after consultation and authorisation is received, from the Registered Practitioner.

20.2 Manager/SSW must ensure that Form M8 is completed and signed by the service users Registered Practitioner, authorising administration.

20.3 All Homely remedies must be recorded and signed for on administration in the MAR chart (Form M9).

20.4 If homely remedies are to be used by a service user, because of the risk of interactions between prescribed medicines and medicines purchased OTC, a service user or relative who purchases a medicine for self-administration, should be encouraged to inform the home's staff that the service user is taking a particular remedy.

20.5 The Care Home need only keep a record when they have an involvement in obtaining the medicines on behalf of the service user.

20.6 There may be different levels of monitoring required of the care staff in respect of service users. This would be part of the ongoing risk assessment.

21. Health Related Procedures

(This list is not exhaustive, and will be added to as new procedures and guidelines are developed.)

22. Training

23. Assessment of Competence

23.1 All staff involved in the Management of Medication will undergo an annual assessment of their competence to practice.

23.2 This will ensure that all staff have the ongoing knowledge and skills required to maintain high standards of practice, and that CSIW standards are achieved.

23.3 The Manager will have responsibility to maintain all records relating to the care staff competency assessments. A copy must be forwarded to the Training Section.


Target Group


Nurse Advisor

Care Home Manager


Care Home Manager/Nurse Advisor

Senior Support Worker (Lead for Medicines)

Night Officer


SSW (Lead for Medicines)

Senior Support Workers


24. Audit

24.1 The processes in use within the Department will be subject to an annual programme of internal and external audit, as follows:

24.2 Internal

24.2.1 The Care Home Manager will have responsibility to maintain all records of audits undertaken and to produce these for external auditors as requested.

24.2.2. External

24.2.2 Glossary of Terms

Administration - This term describes staff responsibility for

Approved Training - Trainings that is accredited

Assessment Staff - Include Social Workers, Care Co-ordinator

Assessor Care Managers,

Welfare Assistants and staff

Audit - Official examination of management of

BNF - British National Formulary. A list of

Care Home - An establishment providing accommodation

Care Home Staff - Include Resource Manager, Registered

Care Plan Objectives identified by an assessment of

Competence based Assessment - Assessed as having adequate knowledge,

Controlled Drugs - Drugs controlled under the provision of the

Controlled Drugs Register - Bound book with numbered pages, which

Covert Administration - The practice of disguising medicines in a

Day Care - Centre that provides care for the service

Dispensed - To make up and give out medicines etc

MAR - Medication Administration Record

Medicines/Medication - Substances with healing properties used in

Monitoring - Maintain regular supervision

NMC - Nursing Midwifery Council

Nutritional Supplement - Provide additional nourishment.

OTC/Homely Remedies - OTC/Homely remedies are non-

Community pharmacist - Person who dispenses medicines

PRN Medicines - PRN is medication that is prescribed or

(as required) authorised by a Registered Practitioner for

Registered Manager - Person registered by the Care Standards

Registered Practitioner - This term covers General Practitioners,

Reviewing - Re-assessment of Needs and the service

Risk Assessment - A systematic examination of all aspects of

Self Administration - This term is limited to making medication

Service Users - The term also means client, customer and

SMDS - Sealed Monitored Dosage System

SSW - Senior Support Worker

Surgical Sundries - Products used to manage a range of

UKCC - United Kingdom Central Council


· National Care Standards Act 2000 - Standard 17, National Minimum Standards for Older People & Standard 20 for Younger Adults.

· National Service Framework for Older People in Wales March 2006.

· The Administration and Control of Medicines in Care Homes and Children's Services - Royal Pharmaceutical Society of Great Britain Publication (June 2003).

· UKCC (NMC) - Position statement on the covert administration of medicines.

· Crooner's Care Standards - A Management Guide.