All Residential Care/Nursing Homes Joint Learning Disabilities Service Sheffield Health and Social Care Trust

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1 APPENDIX 8 All Residential Care/Nursing Homes Joint Learning Disabilities Service Sheffield Health and Social Care Trust STANDARD OPERATING PROCEDURE (SOP) All Schedule 2 Control Drugs and specified others: Schedule 3: Buprenorphine, Temazepam and Midazolam Schedule 5: Oramorph oral solution 10mg/5ml Purpose To ensure that all schedule 2 and the specified schedule 3 and 5 controlled drugs are managed in a safe and consistent manner. To ensure that all legal requirements and good practice recommendations are met in respect of these drugs e.g. Care Quality Commission, Handling of Medicines in Social Care (British Pharmaceutical Society) NMC guidelines, Royal Marsden Clinical Nursing procedures. To provide a robust audit trail for these drugs, from the point of issue by the Community Pharmacist Scope This procedure covers all aspects of controlled drug management for these drugs in all Residential/Nursing Care Homes, Joint Learning Disabilities Service of SHSC Trust. Changes should be agreed by the Trust Accountable Officer for Controlled Drugs who is Peter Pratt, Chief Pharmacist. Aspects of management covered are: Ordering of prescriptions Receipt or collection Storage Administration Record keeping Stock checking Disposal/Wastage Responsibilities Review Training Audit Further guidance on management of controlled drugs can be found in the NMC Standards for Medicines Management 2009 Standard 26, and in the Royal Marsden Hospital Manual of Clinical Nursing Procedures (link on SHSC Trust website). 1

2 1. Ordering prescriptions Medication will only be prescribed by a suitably qualified medical practitioner (In some cases this may include Dental practitioners) Quantities should be based on the length of treatment otherwise a maximum supply of no more than 28 days is recommended Medicines will normally be supplied on a prescription form (FP10) written by a doctor for an individual. It is essential that sufficient information is provided on the prescription form to enable comprehensive labelling of the medicine container by the pharmacist. Every individual receiving medication must have a Medication Administration Record chart (MAR chart). Details of the medication prescribed and administered must be recorded on the Medication Administration Record chart. Administration directions should always appear on the prescription. Where instructions are written using terms such as 'as directed' or 'as before', the member of staff on duty at the time should seek clarification of the prescriber's intentions. Wherever possible, the prescription should be returned to the prescriber for full directions to be entered and clearly marked on the medication label. A pharmacist, who will label each container with the name of the medicine, the person for whom it is prescribed, and directions for use, will dispense prescriptions. The pharmacist should be requested to issue a Medication Administration Record chart for each new prescription/repeat prescription with details of all medications included on the prescription. The labelling of medicine containers should not be changed by staff. Should a label become detached or illegible the container must be returned to the pharmacy for re-labelling. If the pharmacist is unable safely to re-label the container, a further prescription must be obtained from the Doctor. 2. Receipt and Collection Prescriptions for new or repeat medication should be sent to the Residence by the surgery or alternatively it may be collected from the GP surgery by a member of staff, in order that the designated officer or staff member can check the prescription items against the list of treatment requested. Individuals may wish to be supported to collect their own prescription this will be recorded on the MAR sheet and care/ support plan. Prescriptions should not normally be passed directly from the GP surgery to the pharmacy, unless the pharmacist supplies the facility with a copy prescription along with dispensed medicines in order that staff can check that medication has been supplied in accordance with the doctor s prescription. Where a member of staff collects the medication from the community pharmacy, they will be required to provide formal identification. If the pharmacy 2

3 delivers the medication the staff member will be required to sign a receipt if it is a Schedule 2 control drug or specified others. Medicines should only be checked by a trained member of staff (registered nurse in nursing homes) who has been deemed competent to handle and administer medicines. All medicines entering the home must be checked against each individuals MAR chart and current list of medication, to ensure correct medication has been supplied and discrepancies must be immediately reported to the community pharmacy and returned for correct prescription to be supplied. Once you have checked the medication is correct document in the Control Drugs Register the name, strength, quantity of stock received and final balance. This must be witnessed by a second member of staff, who has received training on the safe handling/administration of medication and is deemed to be competent. Each individual must have their own page in the controlled drugs register for each control drug they are prescribed. 3. Storage See guidance in NMC standards. This details requirements for storage cupboards and for key-holding and access arrangements. See also the Duthie Report (DOH 1988) which details responsibilities in respect of medicines storage. This is referred to in the Royal Marsden Manual. The specified Controlled drugs must be stored in a designated Controlled Drugs cupboard when staff are responsible for administering. This is mandatory for all registered care homes ( Care Homes Regulations amendment 2007) 4. Administration All medicines must be administered following the Joint Learning Disabilities Service Administration Guidance available in your local area (Also on the SHSC internet) including extra measures for Controlled drugs; Care homes (Personal Care) Controlled drugs should be given by care workers who have been trained and designated to do so. Another trained and designated member of staff should witness this process. In exceptional circumstances however no one should be deprived of prescribed medicine because there is only one member of staff on duty when he/she needs it (CQC ( The safe Management of controlled drugs in care homes ). This should be risk assessed and extra safety and monitoring should be in place. Care homes (Nursing Care) Care homes (nursing). The administration of controlled drugs and all other prescribed medicines should be by a medical practitioner or registered nurse only. If the resident self-administers his or her medicines, this should be risk assessed and documented in their care plan and MAR Chart. However it would be 3

4 best practice to witness the self administration and safe storage must be available to the resident. 5. Record keeping (Ref. NMC Standards) All specified controlled drugs must be recorded in a Control Drug Register The book must be stored along with the individuals MAR chart and medication information The book is used to record the balances of the specified medications as they are administered. Record receipt, return, or disposal, of medication in the Control Drugs book along with signatures of 2 trained staff this must be a Registered nurses in Nursing homes.(see exceptional circumstances above) Entries in the book should be made in chronological order. Mistakes made should not be obliterated. They may be crossed with a single line, or bracketed, such that the original entry is still legible. This should be signed and dated and witnessed. Before every administration the stock balance must be checked as correct and after the stock balance must be recorded. Any discrepancies much be immediately reported to your line manager who will them follow the medication incident procedure. Peter Pratt Chief Pharmacist SHSC must be informed. Any spillage, refused medication that has been taken out of the packaging for administration, or otherwise spoilt medication, must be documented in the Controlled Drugs Register and returned to the community pharmacist and documented Record books must be retained for 2 years 6. Stock checking Stock checks must be documented in the Control Drug Register and signed by 2 staff members ( registered nurses in nursing homes ) Any discrepancy must be investigated as soon as it is discovered, until it is accounted for. If this does not prove to be possible within a reasonable period of time following discovery, an incident report must be completed, and it must be reported to the identified person and the community pharmacy as soon as possible. If required contact the individuals GP for further supply of the medication. An investigation must be undertaken as soon as possible. Peter Pratt Chief Pharmacist SHSC must be informed. Stock checking must occur as a minimum weekly in addition to the stock control check when administering. If the medication is PRN and not in continual use the above still applies also check expiry dates. It is noted that when using liquids it is hard to count mls of fluid, however discrepancies in liquids must follow the same procedure. 7. Disposal/Wastage When a controlled drug is no longer needed by the individual, inform the community pharmacist. Return the medication to the local pharmacy record the following Date of disposal/return to pharmacy 4

5 Name and strength of medicine Quantity removed Person for whom medication was prescribed Signature of the member of staff who arranges disposal of the medicines. Obtain a receipt from the pharmacist and record in the Control Drug Register with a witness to countersign the appropriate entry in the register. Record any doses, or part doses, wasted, or spoilt for any reason, in the register. Care Homes (personal care).the medication must be disposed of by the community pharmacist Care Homes (Nursing) The Registered Manager must make arrangements to safely dispose of medication through a licensed waste disposal company and retains records of the transactions. The Registered Manager must clarify that the contracted waste disposal company has authorisation to transfer and dispose of controlled drugs. 8. Responsibility The Registered Care Manager/Team Leaders are responsible for the safe and appropriate management of drugs in that area. The Team Leader in charge can delegate control of access (i.e. key holding) to the drug cupboard cabinet to another medication trained staff member. However, legal responsibility remains with the Registered Care Manager. The Registered Care Manager/Team Leaders will ensure compliance with the Standard Operating Procedure. Residential Care Manager The Residential Care Manager or The Designated Medication Officer will carry out a monthly audit of compliance to the SOP. The Designated Medication Officer will investigate any reported incidents of discrepancy which cannot be resolved as soon as possible. This may involve the Assistant Clinical Director/another. Any incidents of discrepancies will be reported via an incident form and to Peter Pratt Chief Pharmacist SHSC Team Leaders/Qualified Nurses All team leaders/qualified nurse s delegated responsibility for administration of medication will ensure that this SOP is followed. 9. Known risks Cupboard security Failure of recording Inaccurate measuring of dose Incorrect identification of patient Misappropriation of drugs 5

6 10. Review October 2013 inline with the Joint Learning Disability Service Local Guidance for the Management of Medicines 11. Training It is recognised various levels of training around Medicines Management and the application of SOP s is required. Medication training is currently being delivered to all support staff consisting of a one day course on knowledge base and including competencies on your individual area with an annual workbook and practical administration. Should a new control drug be prescribed Residential Managers and Team Leaders should ensure that all staff administering medication receives training on site regarding the safe handling of controlled drugs. 12. Audit Monthly Residential Care Manager/Designated Medication Officer Stock check is signed by two trained staff, documented in the register.(registered nurses in nursing homes) No excess stock of drugs specified in this SOP is carried in the stock cupboard The register is stored correctly Incident forms are completed for discrepancies and Peter Pratt Chief Pharmacist is informed Incidents are investigated and a management report completed. Date prepared: October 2011 Prepared by: Alistair Tait Tracey Wear Approved by: Management of Medicines Committee April 2011 Review: October

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