Management of Medicines Policy and Procedure

Overall Aim

Seven Steps Support Ltd is committed to the basic principle that Service Users should be able to exercise maximum personal responsibility over their own lives and decisions, as appropriate to their capacity.

The overall aim of this policy therefore is to promote independence through encouraging Service Users to manage their own medicines as far as they are able, and to administer them in accordance with the advice of their own doctor. It defines who can provide assistance with medicines, what assistance they can provide and in what circumstances. As a result it aims to provide a safe framework for care staff to work within when assisting Service Users with medicines. It also outlines the documentation which should be used and records which should be kept. However, it is acknowledged that it is not possible to anticipate every eventuality, and that in may fall outside of these guidelines e.g. with pain control. In these cases advice will be sought from Health Care Professionals.

Key Principles

Person centred care
To help people remain in or return to their own homes
To promote independence wherever possible
To accommodate personal and cultural preferences
To prevent avoidable admissions to hospital and care homes
To improve the quality of the service provided to people living in their own homes by continually monitoring the service provided
To ensure that any assistance given by Personal Assistants adheres to this policy
To ensure that assistance required is always defined in the Service User’s Care Plan
To ensure that assistance may only be given by Personal Assistants who have received appropriate training and been approved as competent

Service Users have the right to:

Dignity – to be treated with respect at all times
Choice – to be given the opportunity to choose, knowing what choices they have (informed consent)
Realising Potential and Independence – to make the most out of life with full use of available help
Equality and Diversity – to live in an environment free from bullying, harassment and discrimination and in a way the Service User chooses
Safety – to feel safe and to enjoy safety without being over-protected
Privacy – to have personal privacy and to have their property respected All Personal Assistants must be suitably trained and competent for the tasks they are asked to perform and Personal Assistants must feel confident to carry out these tasks correctly and safely. To ensure this, Personal Assistants must always work to ‘Best Practice’ Guidelines and must not carry out any tasks relating to that have not been authorised by their line manager and/or stated in the Service User’s personal plan of care.

Risk Management

Assistance with medicines will only be provided when there is no other means of the Service User managing their own medicines, either through self medication or support from family and friends.

These options must be explored in the first instance. Where it has been established that a Service User requires support with medicine management as part of a package of social care, in order to minimise the risk:

A risk assessment will be carried out initially by the Care Coordinator who will identify the level of support required. Thereafter, the Provider service will monitor the support required.
Medicines training and competence training will be provided to staff appropriate to their grade
The Health and Safety at Work Act 1974 imposes a general duty on employers to ensure, as far as is reasonably practicable, the health, safety and welfare of employees and others which includes Service Users and any others affected by what is done
Personal Assistants must not carry out any invasive, clinical or nursing procedures, such as administering injections, enemas or pessaries (see Summary of Levels of Support) Care Plan must be accessible in the Service Users home

Completion of the Incident Form – ‘Medicines Error’ which will identify an incident, will require the provider to carry out a risk assessment to eliminate or minimise the risk in future.

GENERAL PRINCIPLES OF GOOD PRACTICE IN ASSISTING PEOPLE WITH PRESCRIBED MEDICINES IN THE DOMICILIARY SETTING

Everyone involved in the care of a Service User is responsible for ensuring that his or her medicines is managed appropriately where the Service User is not self-medicating. However, the primary responsibility for the prescription and medicines review rests with the prescriber in consultation with other members of the primary care team and his/her patient.

Medicines prescribed by a Doctor/Nurse/Pharmacist prescriber and dispensed by a Pharmacist become the property of the person to whom they have been prescribed. Whoever administers medicines must make sure that it is administered according to the prescriber’s written instructions and recorded. It will be dependent on the level of assistance required as to where this should be

documented. (See levels of support)

The service will be delivered in a way that enables self-determination and independence. Administration of medicines will be delivered in a way that respects the dignity, privacy, cultural and religious beliefs of the Service User.

Personal Assistants will only provide help with taking medicines, or administer medicines, with the informed consent of the Service User or their relative or representative who may give consent on the Service Users’ behalf. Consent will be recorded on the Medicines Consent Form Personal Assistants will only provide help with taking medicines, or administer medicines when it is requested by the Care Coordinator on the Plan of Care and documented on the Care Plan and ONLY when they have been trained and it is within their competence, within the parameters and circumstances set out in this policy, and when assistance with medicines is part of a ‘package of care’.

Personal Assistants should aim to ensure that Service Users receive appropriate help and encouragement to manage their own medicines but where this is not safe, to ensure that they receive a suitable level of support and assistance with their medicines as indicated in the Personal Plan of Care/Care Plan.

It is acknowledged that Personal Assistants are not health professionals and therefore, must receive appropriate training and formal assessment of their competency undertaken in order to enable them to become competent in the administration of medicines to comply with best practice.

New Personal Assistants will receive a full day of medicines training during their induction period. All other staff will receive a full one days training or two half day training sessions. A competency assessment will be carried out annually.

Assessing the Needs of the Service User

Service Users will be allocated a care package following assessment. An assessment will be completed by the relevant health or social care professional. Medicines will be identified on this assessment and will include how the Service User currently manages their medicines.

Once the Service User has been assessed, the level of support needed with medicines will be decided and added to their care plan. The Care Coordinator will ensure that the support required e.g. request for ordering or prescriptions, collection of medicines from the Pharmacy, and the appropriate allocation of time for the Personal Assistant to administer medicines is recorded in the Care Plan

If, during the assessment by the Social Service team/ Healthcare team, or by the Seven Steps Support Ltd, it is felt that a Service User has difficulty with medicines, but could manage his/her medicines if they were dispensed differently, the Service User’s usual Community Pharmacist may be able to help .Or you may contact the Service Users GP for guidance. It is important that Service Users are allowed to maintain responsibility and remain independent for their own medicines, if at all possible.

Seven Steps Support Ltd is responsible for the care package should ensure that Service User consent has been obtained and recorded on the Personal Plan of Care and that where appropriate; a referral for provision of Medicines Administration Record (MAR) chart has been completed and sent to the Service Users preferred participating Pharmacy.

At the stage of setting up a care package, family members must be made aware that they will be required to co-operate with Personal Assistants when they are carrying out specified tasks e.g. if a Personal Assistant needs to take a chart to the Pharmacy for updating, along with a prescription, then the

family member should not prevent this from happening. Family members/friends will be issued by the Seven Steps Support Ltd with an information leaflet detailing their agreed responsibilities by Seven Steps Support Ltd.

Levels of Medicines Support

Seven Steps Support Ltd will ensure that training is provided and competency assessed for all Personal Assistants providing any level of support and that records of this training are kept. A Personal Assistant must not undertake any related tasks that they do not feel adequately competent to undertake and should inform their line manager of their concerns.

Assistance with medicines will only be provided where the Service User has been assessed via unified assessment, and the exact nature of the assistance specified on the Personal Plan of Care. Assistance with medicines will only be provided where the Service User has been assessed as being unable to administer their own medicines (in full or in part) and there is no informal carer

or other appropriate person to do so and additional social/personal care needs have been identified.

Assistance with medicines will only be provided with the consent of the Service User, obtained when the Personal Plan of Care or the Care Plan is established or reviewed. The Consent Form will be completed at this time. Where informed consent cannot be given, or the Service User is unable to express their views, advice will be sought from their carer, or any other significant person. If necessary, an independent advocate will be used to ensure the best interests of the Service User. In all cases the individual’s general well-being and belief before they became unable to express their views, must be taken into account as well as their physical health. No-one can give consent to treatment on behalf of another adult, but generally health professionals and their colleagues are normally allowed to provide treatment which they believe to be in the best interests of the person, having taken into account the advice from significant persons and carers.

If a Service User cannot give consent because of health reasons e.g. dementia, current recommendations for treating adults with incapacity must be followed. The different levels of support should be considered as a continuum, accepting that Service Users may move up and down the levels depending on their health status and/or functional ability at the time. For example, acute illness may temporarily require more intensive support with medicines; a period of recovery

or rehabilitation may allow Service Users to reduce the level of support they need. Therefore timely and careful review of the Service User’s needs are essential to ensure that any support provided is neither inadequate nor excessive. The process of safely moving Service Users up or down levels can be facilitated and/or managed in consultation with the Service User’s GP and/or the commissioning team.

Levels of Support

Level A Support (DIRECT): The Service User requires no assistance with medicines.

Level B Support (Assist): The Service User retains responsibility for their medicines but may need some additional directed assistance e.g.

Cognitive: The Service User has a small level of cognitive difficulty and requires the Personal Assistant to remind them to take their medicines. (Where possible reminder charts, alarm clocks, family telephone calls should be used). No MAR chart is required. The task of reminding the Service User to take their medicines will be recorded in the Service User’s daily record of care.
Dexterity/mobility: The Service User manages his/ her own medicines, asking the Personal Assistant for help to carry out certain tasks. These tasks must have been consented to and agreed in the Personal Plan of Care, no MAR chart is required. It is the responsibility of the Service User to direct which package/bottle/topical medicines they require assistance with (opened/closed/placed in mouth and stored) and all tasks are completed within sight of the Service User. At no time during assistance is the medicines not within sight of the Service User.

In each of these scenarios, the Service User, and NOT the Personal Assistant, retains sole responsibility for their medicine management and administration. The exact assistance given on each visit should be documented in the Service User’s care plan.

Level C Support (Administer): The Service User relies on the Personal Assistant to manage his/ her medicines. The Personal Assistant will be responsible for administering medicines to the Service User using the MAR chart provided by the Community Pharmacist. The will be provided in its original packaging with a patient information leaflet and will be clearly labelled with instructions relevant to the medicines. This may include oral or topical including eye/ear and nose drops.

Where two or more agencies are working with the Service User, i.e. Community Nurse and Seven Steps Support Ltd, one agency will be nominated as taking the lead for the co-ordination of management issues, ensuring adequate liaison between agencies in the best interest of the Service User. This agency may be either Health or Social Care, and will be agreed on an individual case basis, being

clearly documented in the Service User’s Care Plan.

Understanding Level ‘A’ Support

Level A Service Users take full responsibility for their own medicines and require no assistance with medicines from the Personal Assistant.

It is important to remember that the ability of the Service User may change and that the Personal Assistant is often the only person who will be aware of these changes. If the Personal Assistant identifies any changes in the ability of a Service User to manage his/ her own medicines, this should be reported to the Personal Assistant’s line manager as soon as possible.

Understanding Level ‘B’ Support

These Service Users are responsible for managing their own medicines but may need help with one, or more of all the tasks detailed below, and will be noted in the Service User’s Care Plan. Any requests for further help must be reported as soon as possible to the Personal Assistant’s line manager and, if in a true emergency, extra help has been given, this must also be reported. If this extra help has to continue it must be authorised by the Personal Assistant’s line manager and written into the Service User’s Care Plan.

Important information for Personal Assistants providing Level B Support

Request for further help

Personal Assistants must only give assistance with the tasks documented in the personal plan of care. Any request for further assistance must be reported to the Personal Assistant’s line manager as soon as possible.

Filling pill boxes for the Service User

Personal Assistants must never ‘help’ the Service User by filling compliance aids (these are boxes with compartments for morning, lunchtime, teatime and bedtime). Personal Assistants can assist Service Users to access from a Monitored Dosage System (MDS) that has been filled by a family member/friend at the instruction of the Service User.

Giving Advice

Personal Assistants must never offer their own advice on or recommend that a Service User takes a particular over-the-counter medicine. Queries should be referred to the Service User’s Community Pharmacist.

Assessing capability

Personal Assistants must continually assess whether Service Users are still capable of managing their own medicines. For example:

Is the Service User confused about when to take his/ her medicines?
Is the Service User running out of medicines regularly or have too many left?
Has the Service User's condition changed in any way?
Any concerns about the health of the Service User or the ability of the Service User to maintain responsibility for his/her own medicines must be reported to the Personal Assistant's line manager/out of hours service as appropriate. The Service User should be reassessed with the Service User's agreement, and where appropriate the results should be discussed with the health care team involved in the Service User's care i.e. GP, Community Nurse and Pharmacist.

If however, the Personal Assistant feels that the Service User needs emergency medical help, then the Personal Assistant should telephone 999 immediately and the carer’s line manager should be informed of this as soon as possible.

Service Users who have consumed alcohol

If a Service User has consumed alcohol and is intending to take medicines, the Personal Assistant should advise the Service User to check the labels on the medicines for warning instructions before continuing. It is sometimes not safe to take medicines with alcohol. It is important that such situations are recorded and that the Personal Assistant’s line manager is contacted as soon as possible.

Level B Tasks

Ordering Prescriptions

The Service User or their family/friends will be responsible for ordering their repeat medicines where possible. In cases where this is not possible, the Personal Assistant (following advice from his/her line Manager) may assist the Service User to do this. The Service User must be capable of directing the Personal Assistant and remains responsible for specifying the medicine to be ordered, the dosage

and quantity to be requested. Any assistance given should be recorded in the Care Plan.

Different surgeries will have different procedures for ordering repeat prescriptions and therefore the Service User should inform the Personal Assistant of the procedures used at their own surgery. Some surgeries have a dedicated repeat prescription ordering telephone line, while others rely on the patient filling out the repeat prescription form and returning this to the surgery. Most surgeries will require 2 working days between receiving the prescription request and producing the prescription. It should be noted that more than 2 days will often be needed at weekends and during public holidays.

Collecting the Prescription from the Surgery and taking it to the Pharmacy

Many Pharmacies and GP surgeries now have arrangements for prescriptions to be sent directly to the Pharmacy chosen by the patient. This may mean that Personal Assistants rarely need to collect the prescriptions from the surgeries. The Service User must always be given the choice of which Pharmacy dispenses their medicines and the same Pharmacy should be used for that Service User at all times, allowing the Pharmacist to manage the Service User’s medicines properly by keeping up to date records (see Role of Community Pharmacist)

Collecting Medicines from the Pharmacy

Preferred options for collection of medicines from the Pharmacy where Service Users are unable to do this include family/friends or a Pharmacy delivery service where this is offered. If these are not possible, a risk assessment for the Personal Assistant should be carried out by his/her line manager, and if it is felt appropriate, the Personal Assistant may then be asked to collect medicines on behalf of the Service User. This must be clearly noted in the Service User’s Care Plan

Opening Containers

Should the Service User have difficulty opening medicine containers then the Personal Assistant may give assistance, if requested to do so, and this task is stated in the Care Plan. This may involve taking the top from medicine bottles, opening boxes or helping the Service User to remove tablets or capsules from sealed compliance aids or strip packaging. The Service User’s Pharmacist may be

able to help if this is the only difficulty the Service User has in taking their medicines – they may be able to dispense their medicines differently (e.g. easy open lids etc). However, the Service User will still be fully responsible for taking his/ her own medicines and the Personal Assistant will only be responsible for opening a container at the request of the Service User, not directing him/ her to take or use medicines.

Disposal of Unwanted Medicines

If an appropriate waste licence is required, protocals need to be in place to adhere with the requirements needed for return. Personal Assistants are able to return medicines.

Unwanted medicines must be returned to a Community Pharmacy for safe disposal. The preferred options for returning medicines is for family/friends to do so, or where a delivery service is in operation and Pharmacies have an appropriate licence to carry out pharmaceutical waste, then this option should be used. If a provider has an appropriate waste licence, then Personal Assistants are able to remove medicines from a Service User’s home and return to a Pharmacy for disposal. However, before a Personal Assistant can remove any medicine from the Service User’s home, the Service User/Service User’s representative must be in agreement and sign the ‘Medicine Disposal Form’. On return of the medicines to the Pharmacy, the Pharmacist must sign the ‘Medicine Disposal

Form’, which will be returned to the Personal Assistant and then stored by the Seven Steps Support Ltd in the Service User’s records. Some Pharmacists may wish to keep a copy of the ‘ Medicine Disposal Form’ for their own records.

Complex Regimes

For those Service User who are prescribed more than 8 (eight) different types of medicines, Seven Steps Support Ltd will conduct a risk assessment and, if necessary request a review of care to be undertaken with the commissioning agency.

Understanding Level ‘C’ Support

Service Users at Level C have been assessed as being unable to manage their own medicines and as requiring the Personal Assistant to assist with and be responsible for their medicines. It should be noted that even the ‘selection’ of requested/prescribed medicines forms part of the administration process and as such, the Personal Assistant is responsible for the selection and administration of the medicines.However, it is important to maintain the Service User’s dignity and independence at all times, and so where possible the Service User should be encouraged to engage with the Personal Assistant in the process of medicines administration, such as giving explanations of the procedure and encouraging the Service User to manipulate packaging where they are still able. In such situations, the Personal Assistant remains responsible for selecting and administering the appropriate medicines as per the instruction on the medicines label and as per the MAR chart.

Important Information for Personal Assistants providing Level C Support

Administering Medicines to Service Users

Personal Assistants can assist Service Users with their medicines, provided they have been appropriately trained, that the medicine has been prescribed and the written directions of the prescriber are followed. These directions will be on the medicine label and the MAR chart.

Personal Assistants can give or assist people in:

• Taking tablets, capsules, oral mixtures

• Inserting drops to ear, nose or eye

• Administering inhaled medicines

• Apply a medicated cream/ointment to skin that is unbroken. Personal Assistants should NOT apply medicated cream/ointment to broken skin/lesions/wounds.

Administering medicines to Service Users requiring Level C support

Each time a Personal Assistant administers a medicine to the Service User the procedure for administration of medicines must be followed.

Personal Assistants can only give assistance with medicines if the tasks have been written into the Care Plan a copy of which will be kept in the Service User’s home. Medicines can only be given to the Service User if it has been written onto a MAR chart.

The use of Medicines Administration Record (MAR) Charts

The commissioning agency/Seven Steps Support Ltd who assesses the Service User as Level C support is responsible for referring the Service User to the Community Pharmacist for the initial production of the MAR Chart using the appropriate referral form (Referral to Community Pharmacist) for provision of MAR charts. It is noted that not all pharmacies are able to supply MAR charts and, where appropriate, it may be necessary to devise an internal chart for use by Seven Steps Ltd staff.

Where there is a delay in acquiring a MAR chart from a participating Community Pharmacy, a hand written chart may be completed and used for no more than four working days. Completion will be by a Medicines Manager of Seven Steps Support Ltd and MUST be checked by a second individual, signed and dated. If this occurs, it should be recorded in the Care Plan.

The MAR Chart will be delivered to the Service User’s home by a senior staff member of Seven Steps Ltd. This is not a task expected of Personal Assistants. kept in the Service User’s home with the medicines and must state the name and dose of the medicines to be given to the Service User and all Personal Assistants must be aware of these details. All Personal Assistants must complete the MAR Chart when assisting with medicines and Seven Steps Support Ltd will be responsible for removing this at the end of each month and replacing it with a new sheet.

Seven Steps Support Ltd is responsible for audit of the MAR Chart. A new MAR Chart will be produced by the Community Pharmacy every twenty eight days or when a new medicines is prescribed and the old MAR chart should be removed. These sheets must be stored by Seven Steps Support Ltd in the Service User’s records in a central location for three years. At this stage the line manager will ensure that there have been no problems during the previous month and if problems have arisen they must be dealt with immediately.

Alterations and errors (MAR charts)

Any alterations to MAR charts can only be made by a qualified health professional and should be dated and signed.

Errors must not be obliterated by tippex or biro. Any errors made when signing the MAR chart should be crossed through with an X and details recorded on the ‘Medicines Administration: Additional Information Record’ which will be with the MAR chart. Where a Personal Assistant finds that this has occurred and they are therefore unable to place their initials in the appropriate box when administering the medicines, they should instead document and sign that they have administered the medicines on the Medicines Administration: Additional Information Record.

In some circumstances a new MAR chart may need to be arranged.

Use of Medicines Administration: Additional Information Record

Personal Assistants should record any relevant additional information on this record which should be kept with the MAR chart. Information may include:

Information on errors made when signing MAR chart
Follow up from “4 later”
Ordering and removal of medicines
Any information or alterations made to the MAR chart by health professionals
Any other relevant information that requires documentation

Administration of Warfarin

All Level C Service Users taking Warfarin must be referred to the Medicines Manager at Seven Steps Ltdto undertake a risk assessment and assessment of the level of support actually required. Where possible, family support should be sought and facilitated.

Where Warfarin is assessed as simple/stable, it can be written on to the MAR chart (or dispensed into a MDS) by the Community Pharmacist and treated like any other medicine and administered in the usual way by Personal Assistants. The Medicines Manager will review these Service Users at a minimum of 3 monthly intervals. Where Warfarin is assessed as complex/unstable, the Personal Assistants will NOT administer and other arrangements will be negotiated with the commissioning agency.

Shared Care

If more than one Provider is responsible for assisting the Service User with medicines, then the person setting up the care package must designate a Lead Provider (usually the Provider giving most support with medicines). This Care Provider will be responsible for ensuring new MAR Charts are in place, and storing completed MAR charts. Personal Assistants from both provider service will use the same MAR chart when assisting with medicines. Each Provider will be responsible for the actions of their own care staff.

“When required” (prn) medicines

Some Service Users may have medicines prescribed as ‘when required’ (e.g. painkillers, inhalers, etc) that they only need to take occasionally. The indication for the when required medicine should be included on the MAR chart and label e.g. “for pain”, “for sleep” “for indigestion” etc. If this information is not included the Community Pharmacist should be contacted for advice. Service Users should be asked whether they require each of these medicines at the intervals stated on MAR/label and they should not be given where they are not required.

“When required” items needed for immediate relief of symptoms should be accessible to patients e.g. GTN spray for angina or relieving inhalers. Pharmacists will be able to highlight these items.

Use of Monitored Dosage Systems (MDS)

MDS such as dosette, nomad etc, are currently being phased out as a means of assisted administration due to clinical governance issues.

In domiciliary care, it may be appropriate for a Service User to have access to medicines in between care calls, e.g. sleeping tablets or medicines for pain relief. In such circumstances doses may be left out for that individual to take at a later time. This can only be undertaken where it has been risk assessed by the Medicines Manager as appropriate, agreed with the Service User, and it is documented in the Care Plan. Doses administered ‘4 later’ are recorded on the MAR with the number 4 instead of the Personal Assistant’s initials. The next Personal Assistant to visit should check that this ‘4 later’has been taken by the Service User. Where the Service User has not taken this medicine, the Personal Assistant must dispose of them as they would for any refused (see ‘Disposal of refused medicines’ below), and this should be recorded on the Medicines Administration: Additional Information Record.

Inhaled Medication

Normally in domiciliary care a Service User should be able to physically administer their own inhaled medication, as there may be times when the Service User needs to use the inhaler when no one else is present.

If it is noted during the Assessment or during care visits that the Service User is having difficulty using their inhaler these concerns should be brought to the attention of the prescriber and a request made for a review of the Service User’s inhaler technique.

Following the inhaler assessment if the Service User is able to use their inhaler but has problems remembering when to take their Preventer Inhaler, they may be assisted to administer their own inhaled medication to prevent a condition from worsening via a direct verbal instruction from the Personal Assistant. This direct verbal instruction is recorded on as level B administration.

If the Service User is unable to use any inhaler device available then consideration should be given to allowing Personal Assistants to administer the inhaled medication. This can be done via Level C Specialised Administration and changing the device to an MDI (Monitored Dosage Inhaler) plus a spacer device. Due to the nature of domiciliary care where Service Users may be on their own in between care visits, this needs to be fully risk assessed including the Service Users ability to use their inhaler for acute needs.

The process for assisting the Service User with an MDI Inhaler and a spacer device for Level C Administration would be;

If spacer device requires assembling carer would do so following directions in patient information leaflet.
Take mouthpiece off inhaler and shake device
Fit onto spacer
Press down once on top of inhaler to release medication
Ask Service User to breath out first
Pass device to Service User to place in own mouth (with inhaler still attached)
Ask Service User to take in one slow deep breath or 2-3 normal breaths to make sure medication gets into the lungs.
If second dosage/puff is required wait one minute and repeat process.

Reliever Inhalers e.g. Ventolin or Salbutamol Inhalers

Personal Assistants should not normally assist Service Users to administer inhalers used for acute symptoms, commonly called Relievers –these inhalers normally have a ‘when required’ dose and Service Users need to be able to use these inhalers at any time, whether or not a Personal Assistant is present.

If Service Users are identified as having problems this must be brought to the attention of the GP or Practice Nurse to enable them to risk assesses the situation.

In the case of emergency situations where the Service User is suffering an acute episode the Personal Assistant should call 999 and follow the directions of the Emergency Services.

Keeping a record of the initials and signatures of all Personal Assistants

A record of the printed names, signatures and initials of all Personal Assistants must be kept by Seven Steps Support Ltds. This is extremely important when Personal Assistants are initialling MAR charts.

Service Users refusing medicines**

The Personal Assistant must never force a Service User to take medicines. If a Service User refuses the Personal Assistant must make a note on the MAR chart. The health of the Service User may be affected if is not taken. It is recommended that the Personal Assistant seeks advice from the Pharmacist either directly or via the Personal Assistant’s line manager. Any advice given will be recorded. This does not apply to medicines which are taken only when required.

Disposal of refused medicines**

If the Service User refuses to take medicines before it has been taken from the packaging, then the medicine will be kept in the package and the Personal Assistant will record that the medicine was refused on the MAR chart (use the appropriate code). If medicine has been prepared for giving to the Service User by removal from the container and then it is refused, then this medicine should be placed in the ‘REFUSED’ bottle. It should be recorded on the MAR chart that the medicine was ‘refused’ and the Personal Assistant should sign for this action.

At the end of the month the person responsible for collecting new medicines (family or Personal Assistant) from the Community Pharmacy should return the refused medicines to the Pharmacy, having completed the ‘Medicines Disposal’ Form and a new bottle obtained.

Service Users who have consumed alcohol

Personal Assistants giving Level C support must not give medicines with alcohol warnings on the labels to a Service User who has consumed alcohol until their line manager has been contacted and they have been given permission to proceed.

The line manager will contact the Pharmacist/ GP for advice. This must be clearly recorded. If the line manager cannot be contacted, the Personal Assistant must contact the Out of Hours Service/Pharmacist/GP or NHS Direct for advice, again recording any advice given on the Medicine Administration: Additional Information Record sheet. This should then also be reported back to the line manager as soon as practicable.

Mistakes or incidents

Errors can occur in the prescribing, dispensing or administration of medicines. Most errors do not harm the individual although a few errors can have serious consequences. It is important that errors are recorded and the cause investigated so that we can learn from the incident and prevent a similar error happening in the future.

Examples of administration errors are:

Wrong dose is given, too much, too little
Medicines is not given
Medicines is given to the wrong Service User
Medicines given at the wrong time

Errors must not be ignored and a culture that allows staff to report incidents without the fear of an unjustifiable level of recrimination must be encouraged. Managers should adopt a first line approach of assessing Personal Assistant’s competency and provide additional training where appropriate.

Repeated errors

Despite additional support, where repeated errors occur, may lead to alteration of duties.

All errors and ‘near misses’ must be reported by completing an Incident Form – ‘Medicines Error’ which is forwarded to the Medicines Manager in the first instance. All reports should be investigated to decide whether additional training or a review existing procedures needs to be undertaken. Serious incidents must be reported to the CQC, in accordance with regulatory requirements.

Personal Assistants must immediately report any error or incident in the administration of medicines to their line manager/out of hours service who will then contact the GP or Pharmacist as appropriate. If the line manager cannot be contacted the Personal Assistant will contact the GP/ Pharmacist/out of hours services directly and details of the advice given should be recorded on the Medicine Administration: Additional Information Record sheet. The carer’s line manager should be informed as soon as possible.

Ordering Prescriptions

Only medicines listed on the MAR chart should be ordered. Whenever possible family/friends should be responsible for monitoring stock and ordering repeat prescriptions. However if there are no family or friends available, the Seven Steps Support Ltd will highlight on the Care Plan that 5 days prior to the MAR chart expiry date, the Personal Assistant will order a repeat medicines and MAR chart from the GP/Community Pharmacist

Collecting Prescriptions from the surgery and Collecting Medicines from the Pharmacy

Storage of medicines

Personal Assistants supporting Service Users at Level C must ensure that medicines are stored in a suitable place, within a lidded box to allow safe administration of medicines in accordance with the procedure. It is not always necessary for this to be a lockable box, and this should be risk assessed on an individual basis.

In some cases it may be appropriate to store medicines in a place where the Service User cannot get them. This will usually take the form of a lockable box issued via the Medicines Manager. In this situation the location of the medicines should be documented in the Care Plan consent must be gained from the Service User or family member to store their medicines in this way. It is also important to note that certain ‘as required’ medicines must never be locked away and should remain available to the Service User at all times. Where on assessment the Service User is deemed to be at risk from these ‘as required’ medicines, then this should be discussed with the prescriber. Such medicines include; reliever inhalers (such as salbutamol), glyceryl trinitrate spray (GTN spray).

Disposal of medicines – the same procedure as for a Service User under Level B (page 15)

Insurance

Seven Steps Support Ltd has adequate insurance for all the tasks relating to medicine administration that they ask Personal Assistants to carry out.

Complex Regimes

For those Service User who are prescribed more than 8 (eight) different types of medicines, Seven Steps Support Ltd will contact the Medicines Manager for a risk assessment and a review to be undertaken

Roles and Responsibilities of the Seven Steps Support Ltd

To ensure a duty of care to Service Users (taking reasonable care to avoid acts or omissions which may cause harm to Service Users).
They are responsible for ensuring that care staff act in ways which are within the law and consistent with the policy and procedure.
To ensure Personal Assistants are provided with information, instructions and training which enables them to competently carry out their duties as described in this policy. Training must be updated regularly to ensure competency.
To ensure Personal Assistants are competent to out tasks as specified in the Care Plan through supervision and monitoring.
To ensure Personal Assistants are not undertaking carry inappropriate tasks.
To liaise with care management to ensure that the Care Plan accurately describes the support the Personal Assistant is being asked to provide.
To liaise with the medicines management nurse regarding queries and other healthcare professionals as appropriate (e.g. GPs, Community Nurses, and Pharmacists etc).
As part of arranging a package of care, the Provider will be responsible for referring to the Community Pharmacist or the Medicines Managerfor provision of a MAR chart.
To monitor the quality of completed MAR chart and take any appropriate action.
Ensure appropriate storage of MAR charts for a minimum of three years.

Roles and Responsibilities of the Personal Assistant

To follow the procedure when administering medicines.
The role of the Personal Assistant in the Community is to enhance the independence of the Service User.
They must have received appropriate training, and been assessed as competent, before assisting in the administration of medicines.
Personal Assistants must notify their line manager where they are being asked to provide assistance with medicines which deviates from this guidance.
Personal Assistants must not provide advice regarding medicines. They must seek clarification and guidance from their line manager if queries arise.
Personal Assistants must adhere to this policy and procedure at all times.
Personal Assistants must not apply antiseptic cream ointment to broken skin lesions If in doubt medicines must not be given and advice sought.

Role of the Community Nurse

The Community Nurse will have a major input into the care of many Service Users and the Personal Assistant must therefore work closely with the Community Nurse. The Community Nurse will provide an effective link with the Service User’s GP.

The Community Nurse will, where appropriate, provide specialist training for Personal Assistants and is a good source of advice for Personal Assistants regarding the care and well being of the Service User.

Role of Specialist Nurses

Specialist Nurses, such as Community Psychiatric Nurses and Palliative Care Nurses (nurses who care for patients who have long term chronic illnesses or terminal illnesses such as cancer), may also be involved in caring for a Service User. Again, it is important for Personal Assistants to work closely with these nurses.

Role of Specialist Community Services

Medicines issues may be identified and assessed by specialist services such as Early Response Service and Reablement Services. Such services may undertake the process of safely moving Service Users within their caseload up or down levels of support, facilitated by the Medicines Manager if needed. Where possible the Service User’s difficulties with medicines will be resolved as the Service User regains independence. Advice and guidance may be sought from the referring agency, as appropriate and the service will ensure effective communication with Seven Steps Support Ltds to promote a seamless transfer of care to domiciliary services.

Such services may contribute to measuring outcomes, auditing and monitoring processes for medicines management undertaken by Seven Steps Support Ltd

Role of the Community Pharmacist

The Service User’s Community Pharmacist will be able to provide general advice on medicines such as when they should be used, how to take them, how to dispose of them, side effects, interactions and over the counter medicines. The Pharmacist and can be contacted for advice by the Service User or on behalf of the Service User by family or carers where appropriate. However, if the medicine has a prescription label that states ‘as directed’ this must be referred back to the Service User’s General Practitioner as the Pharmacist would not have been privy to the information provided at the time of the original prescribing.

A Service User’s Community Pharmacist may be able to provide solutions to help the Service User manage their own medicines. The Pharmacist has the expertise to decide the best solution and eligibility of individual patients. Any information that can be provided to the Pharmacist (with the consent of the Service User) regarding the patient’s needs and abilities will help in finding a potential solution. Examples include the provision of large print labels, reminder charts, containers that are easier to open etc.

Different Pharmacies offer different levels of support and services. Many Pharmacists now offer a service whereby repeat prescription from the GP is sent to the Pharmacist who then deliver the medicines to the Service User.

Administration Record chart (MAR) service

Where a Service User is unable to manage their medicines themselves, care staff may have a role in administration (Level C). In these cases, a MAR system needs to be in place. MAR charts are available from participating Pharmacies following assessment of patient’s needs by the Medicines Management Nurse or suitably trained Case Manager. NB not all Community Pharmacies currently provide this service. Service Users may need to be offered a choice alternative Pharmacies in the area who do provide this service.

Usage Review (MUR) service

Service Users who are able to visit their Pharmacy may benefit from a medicines usage review. This involves a consultation with a Pharmacist in a private area of the Pharmacy during which the Service User can discuss their medicines, including what they are for, how to take them, side effects and tips of how to organise medicine taking.

It is important that the Personal Assistant always uses the Community Pharmacy chosen by the Service User. This means that the Service User’s records will be kept up-to-date.

The Community Pharmacist must know the level of support that is required because this will influence decisions the Pharmacist may need to make about the Service User’s medicines.

The Community Pharmacist is a readily accessible source of support for staff and may be able to assist them in managing Service User’s medicines in the following ways.

Dispensing prescriptions
Advice on prescription medicines
Advice on over-the-counter medicines, including interactions with prescription medicines
Advice on chronic medical conditions, such as asthma and diabetes
Utilising the emergency supply regulation to aid Service Users should they run out of previously dispensed medicines.
Advising care staff on possible side effects of medicines either prescribed or purchased for Service Users.
Offering advice via the telephone to carer/ and or Service User safely disposing of unwanted medicines to avoid the hoarding of medicines
Advising on the availability of alternative dose forms e.g. if the Service User has difficulty with swallowing
A collection and delivery service may be available for prescription medicines
There may be the opportunity to use an Electronic Prescription Service whereby the prescription is sent directly to the nominated Pharmacy.
A wide range of leaflets on health related issues may be available
Pharmacists may be able to liaise with hospital Pharmacies on discharge
problems
Production and updating of MAR charts for use by Personal Assistants providing Level C support

Pharmacies will have a practice leaflet available to customers describing the range of services they offer.

Guidelines and Procedure for the Safe Administration and Management of Medicines

1. INTRODUCTION

1.1This procedure must be read in conjunction with the Policy for the Administration of Medication and the Medication Administration Training Pack for Domiciliary Care Assistants.

1.2 This procedure promotes the safety and well being of the Service User and provides a framework of safe practice for the Personal Assistant.

1.3 This procedure must be followed when Personal Assistants are required to assist with medication, or administer medication to Service Users who are not able to manage their medication themselves. This requirement will be stated in the Care Plan as a level B or C

2. OBTAINING PRESCRIPTIONS AND DISPENSED MEDICATION

2.1 Obtaining prescriptions – If the personal plan of care requires a repeat prescription to be ordered, the Care Provider will indicate on the Care Plan that 5 days prior to expiry of the MAR chart, the Personal Assistant is to order /MAR chart from the GP/Pharmacist. Personal Assistant must not over order or stockpile .

The Personal Assistant:

must clearly indicate on the repeat request slip only which medicines are required
must take into account the expiry date of the MAR chart and order from the GP/Pharmacist – 5 days, or as per local protocols.
the Personal Assistant must only use the Service Users preferred Pharmacy which will be documented on the personal plan of care (NB the chosen Pharmacy must be able to provide a MAR chart to allow Level C administration by Personal Assistants)

2.2 Obtaining dispensed medication – In cases where the Service User or Service Users’ representative is unable to obtain dispensed medication, one of the following methods of obtaining medication will be documented in the Care Plan:

the prescription requires collecting from the surgery and taking to the Pharmacy for dispensing
the Pharmacy will collect the prescription from the surgery and the dispensed medication should be collected from the Pharmacy
Personal Assistants should check the delivery of such medicines to ensure that the correct amount and correct medicine has been provided. This should be recorded on the MAR chart or other documentation, as devised by Seven Steps Support Ltd.
the Pharmacy will collect the prescription from the surgery and arrange delivery of the dispensed medication to the Service Users’ home Where the care provider is responsible for obtaining supplies of medicine on behalf of the Service User, the Personal Assistant should check that there is enough to last for the next few days and to order medicines as agreed in the Care Plan.
All unused regular and refused medication should be returned to the Pharmacy at the end of the month. HOWEVER, all ‘as required’ medication which is unused should be retained and used as directed on the new replacement MAR chart. This should be documented in: Level C: the Medicines Administration: Additional Information Record Level B: Record Book It is important not to over-order medicines. Before ordering, the Personal Assistant should check the amount of medicines the Service User has and only order what is required rather than every item. Particular care should be taken when ordering ‘as required’ medications. Running out of a medicine because of ‘bad housekeeping’ should not be an excuse to contact emergency services.

3. STORAGE OF MEDICINES

3.1 Medicines must be stored in a cool, dry place unless otherwise stated on the label (for example some medicines must be stored in a fridge).

3.2 All medicines must be kept out of the reach of children.

3.3 Locked boxes will be provided (while current stock lasts) via the Medicines Manager to those Service Users at high risk of over medicating if they have free access to their medications. However, it will be the responsibility of the Seven Steps Support Ltd to supply locked boxes. Other Service Users will be asked to provide a suitable sized lidded box e.g. plastic food storage container, shoe box etc. These boxes will be used to store the medication and MAR chart. Any special storage instructions for medicines will be identified on the label and should be followed e.g. keep in fridge. In certain cases where a Service User has particularly large numbers of medicines, a second lockable box may be needed to store spare stock, particularly during the period of overlap where repeat medications arrive as the remaining previous stock is still being used up. In such cases the second box should be clearly labelled as box 2 Spare Stock, and noted on the Care Plan. To minimise the need for this, please ensure medicines are not over ordered.

3.4 It is advisable that medicines should not be stored in kitchens or bathrooms due to high temperature and humidity. (Unless to do so would significantly cause the Service User to become confused and so lose independence).

3.5 Medicines must be kept in their original container as provided by the Pharmacy and must not be removed until the time of administration. This means that doses of medicines should not in general be put out in advance of administration in egg-cups or medicine pots as it can lead to accidental mix-ups and errors. However, it may be appropriate for a Service User to have access to medicines in between care calls, e.g. sleeping tablets or medicines for pain relief. In such circumstances doses may be left out for assisting people with that individual to take at a later time. This can only be undertaken where it has been risk assessed as appropriate, agreed with the Service User, and it is documented in the Plan of Care. Doses administered ‘4 later’ are recorded on the MAR with the number 4 instead of the Personal Assistant’s initials. The next Personal Assistant to visit should check that this ‘4 later’ medication has been taken by the Service User. Where the Service User has not taken this medicine, the Personal Assistant must dispose of them as they would for any refused medication (see ‘Disposal of refused medication’ page 18), and this should be recorded on the Medicines Administration: Additional Information Record.

Assisting people with Medication Administration Procedure Level B administration:

Reminding

Introduce yourself to the Service User – if this is the first time the Personal Assistant has worked with the Service User. Once the relationship has been established and the Service User is comfortable with the Personal Assistant, ‘introduction’ will not always be necessary.
Check the Care Plan for instructions on medication
Remind the Service User to take their medications and observe that they carry this out.
The exact assistance given on each visit should be documented in the Care Plan

Assisting

Introduce yourself to the Service User - if this is the first time the Personal Assistant has worked with the Service User. Once the relationship has been established and the Service User is comfortable with the Personal Assistant, ‘introduction’ will not always be necessary
Check the Care Plan for instructions on assistance
Discuss with the Service User their medication requirements.
Taking directions from and in the full view of the Service User, give assistance to the Service User as requested by them.
Ensure that the Service User is able to remain in control of their own medication.
The exact assistance given on each visit should be documented in the Care Plan. NB. If at any time you feel that the Service User is not aware of the medication they are taking STOP ASSISTANCE AND PHONE YOUR LINE MANAGER FOR ADVICE AND REASSEMENT.

Level C administration using a dosette box (MDS)

Introduce yourself to the Service User - if this is the first time the Personal Assistant has worked with the Service User. Once the relationship has been established and the Service User is comfortable with the Personal Assistant, ‘introduction’ will not always be necessary -
Ensure the environment is free of distractions e.g. ask the Service User to turn the television off if this helps you to concentrate better
Check Care Plan for instructions on medication
Choose the appropriate compartment, remove tablets and give to the Service User to take. Record medication given from dosette box in the Care Plan and record on the MAR Chart

Level C administration using a MAR Chart and original containers

Introduce yourself to the Service User -if this is the first time the Personal Assistant has worked with the Service User. Once the relationship has been established and the Service User is comfortable with the Personal Assistant, ‘introduction’ will not always be necessary
Ensure the environment is free of distractions e.g. ask the Service User to turn the television off if this helps you to concentrate better
Check Care Plan for instructions on medication
Explain that you will need to check the medication to see if any is to be given prior to food.
Find a clean area free from clutter
Open medicines box - ask Service User if they have taken any medication already and check the MAR chart to ensure that none of the medicines have already been given/signed for. If you have reason to believe medicines have been taken already STOP PROCEDURE and inform line manager.

Otherwise continue as follows:

Remove all medicines from the box, checking as you do that they all have the Service User’s name on them.
Assemble all of the equipment needed to administer the medication such as 5ml spoon, MAR chart,gloves etc.
Organise the medications as follows: Using the MAR chart in conjunction with the labels on the medication boxes, go through each checking the five rights (Right Service User, Right time, Right medicine, Right to effuse, Right dose, Right route), ensuring that the instructions on the MAR and labels match. Check the label for any special instructions before administering the medicine e.g. does it need to be taken before or after food? Should the Service User avoid alcoholic drink? Does the medicine need to be dissolved or mixed with water before taking? Should it be swallowed whole not chewed? Etc. Please ensure that these additional instructions are followed. Some medicines should only be taken “when required” to relieve symptoms e.g. pain killers, laxatives, sleeping tablets, inhalers, GTN spray for angina. If the Service User has been prescribed Alendronic Acid, this must be administered before food and any other medicines (first medicine of the day) and they must be sitting upright when administration takes place and for 20-30 minutes after the medicine has been taken. The Service User will need to be asked whether they need these medicines and they should not be given routinely. (If you are not sure what a “when required” medicine is for, please consult the patient information leaflet insider the medicines container or contact the Community Pharmacist.

As you are doing the above, place the medicines as follows:

Medication to be taken before food -placed to one side on the lid.
Medication to be taken with or after food -on the other side of
The lid, along with any other to be taken at this time.
Medication not required at this call – placed inside the box out of the way.
Where there is more than one container of the same put spare containers into the box and the pack to be used on the lid. Any medication that needs further clarification: place this in the box and make an immediate written note to contact the Medicines Manager, Community Pharmacist or out of hours services (as appropriate) for further information. If you always do this the same way then if you become distracted for any reason it is easy to see where you have got to. Always use the MAR chart AND the medication boxes as your point of reference (if then for any reason you have missed something it will be left outside of the box for you to clarify)Always check the previous box to ensure the signatures are in place for administered medicines, there should be no gaps in the MAR chart.

Wash and dry hands. (Gloves should be uses for creams/ointments/drops)
Before administering, check any expiry dates highlighted on the label e.g. for eye drops and liquids. Also check when removing strip from the box that the name of the drug on the strip matches that on the container.
Following the MAR chart AND the boxes administer any medication that should be given before food, one medicine at a time, and sign the MAR chart after each is administered.
Continue to assist with other activities, such as personal care, and if more medicines are to be taken after food, ensure that Service User has something to eat.
Wash and dry hands. (Gloves should be uses for creams/ointments/drops)
Following the MAR chart AND the boxes administer any medication that should be given after food, one medicine at a time, and sign the MAR chart after each is administered. NB with ‘As Required’ medicines, ask the Service User whether they need these medicines as they should not be given routinely.
Topical medicines (creams/ointments/drops) have expiry dates. The date of first opening needs to be clear on the receptacle and checked each time to ensure the expiry date is not overlooked e.g. 28 days from date of opening.
Once all medication has been administered check that no boxes/bottles are left over, wash and dry any utensils, and return everything to its original place ensuring box is locked (if appropriate).

Refusal

The Personal Assistant must never force a Service User to take medication. However, if they are refusing a medicine it is useful to ask them why they do not wish to take it, as this may need to be discussed with GP. The health of the Service User may be affected if medication is not taken. It is recommended that the Personal Assistant seeks advice from the Pharmacist either directly or via the Personal Assistant’s line manager. Any advice given will be recorded.

If the Service User refuses the medication, record this on the MAR chart using the appropriate code indicated at the bottom of the chart (this may be different for each Pharmacy)
If medication has not been removed from the original container then leave in place.
If medication has been removed from the original container then place in the refused/dropped bottle which should then be returned to the Pharmacy at the end of each month for disposal.
All changes in the Service User’s condition including refusal of regular medication should always be reported to Service User’s GP (This does not apply to refusal of medicines which are taken only when required). REMEMBER DO NOT administer medicines from unlabelled containers. For Level C Service Users DO NOT administer dosette boxes (MDS) that have not been filled by a Pharmacist If you are in doubt about anything, DON’T administer and seek advice from the Medicines Manager.