MEDICATION POLICY FOR DOMICILIARY CARE

Transcription

1 NEATH PORT TALBOT COUNTY BOROUGH COUNCIL CYNGOR BWRDEISTREF SIRIOL CASTELL-NEDD PORT TALBOT MEDICATION POLICY FOR DOMICILIARY CARE

2 Policy: Document Purpose: Title: Author: READER INFORMATION Neath Port Talbot County Council, Social Services Health and Housing Directorate. Policy developed in collaboration with Neath Port Talbot LHB and Bro Morgannwg Trust Good Practice Guidance Publication Date: May 2008 Assisting People with Prescribed Medication in the Domiciliary Setting Medicines Management (Domiciliary Care) Steering Group Review Date: For use by: For information by: Superseded Documents: Timing: Contact details: November 2008 and thereafter annually. NPT Homecare Services, Social Services Care Management staff, Independent Providers of Homecare Pharmacists, Community Nursing staff, Contracting staff Policy for the Administration of Medication August 2006 For implementation from May 2008 Further copies of this document are available from the Principal Officer, Direct Services Older and Disabled People and the Neath Port Talbot Social Services Intranet 2

3 Following wide consultation, this policy has been agreed by the Domiciliary Care Medicines Management Steering Group, and consists of the following members: Director of Nursing Head of Prescribing & Medicines Management Principal Officer Direct Services Older and Disabled People Operational Manager Homecare Contracting Officer Medicines Management Nurse (MMN) Head of District Nursing Reablement Nurse representative Union Representative Neath Port Talbot LHB Neath Port Talbot LHB Neath Port Talbot CBC Social Services, Health and Housing Neath Port Talbot CBC Social Services, Health and Housing Neath Port Talbot CBC Social Services, Health and Housing Neath Port Talbot LHB/ Neath Port Talbot CBC Social Services, Health and Housing Bro-Morgannwg Trust NPT Reablement Service UNISON/GMB This policy will be kept under review by the Policies, Procedure & Hospital Discharge Working Groups (Domiciliary Care) and consists of: Principal Officer Direct Services, Older Neath Port Talbot CBC Social Services, and Disabled People Health and Housing Operational Manager Homecare Neath Port Talbot CBC Social Services, Health and Housing Contracting Officer Neath Port Talbot CBC Social Services, Health and Housing Principal officer Care Management Older Neath Port Talbot CBC Social Services, and Disabled People Health and Housing Pharmacist representative Local Health Board Medicines Management Nurse Neath Port Talbot LHB/ Neath Port Talbot CBC Social Services, Health and Housing District Nursing representative Bro-Morgannwg Trust Union Representative UNISON Team Manager Care Management Neath Port Talbot CBC Social Services, Health and Housing Domiciliary care supervisors (x3) Neath Port Talbot CBC Social Services, Health and Housing Hospital discharge working group Director of Nursing Bro Morgannwg NHS Trust Medicines Management Nurse Neath Port Talbot LHB/ Neath Port Talbot CBC Social Services, Health and Housing Team Manager Hospital Team Neath Port Talbot CBC Social Services, Health and Housing Head of Pharmacy Neath Port Talbot Bro Morgannwg NHS Trust Hospital Pharmacist representative Local Health Board Ward Pharmacist representative Bro Morgannwg NHS Trust Ward Manager representative Bro Morgannwg NHS Trust Unified Assessment Coordinator Bro Morgannwg NHS Trust Head of Prescribing & Medicines Neath Port Talbot LHB Management 3

4 Implementation & dissemination: Ownership of this policy rests with Neath Port Talbot Social Services. Dissemination to locality teams will occur alongside the training of care staff. Future organisational changes involving roles or job titles should not affect the processes outlined in this policy. Where any future organisational changes occur which do affect the operation of this Policy, the Policy & Procedure Working group will review the Policy and agree any necessary changes. The policy will be subject to review by the group in November 2008, and thereafter at least two years or earlier if significant changes occur. 4

5 Contents Section Title Page 1 Introduction 5 2 Legislation and Statutory Requirements 6 3 List of References 6 4 Purpose and Scope Overall Aim Key Principles 7 5 Risk Assessment 8 6 General Principles of Good Practice 9 7 Assessing the Needs of Service Users 10 8 Levels of Support Understanding Level A Support Understanding Level B Support Understanding Level C Support Summary of Levels of Support 21 9 Roles and Responsibilities Care Coordinator Medicines Management Nurse Care Provider Care Worker District Nurse Specialist Nurse Specialist Community Services Community Pharmacist Policy Dissemination Appendices 1. Consent Form Referral to Pharmacist for Provision Of MAR Chart Leaflet for Relatives/Friends Medication Management Nurse Referral Form MAR Chart Medication Disposal Form Guidelines and Procedure for the Safe Administration 35 And Management of Medicines 8. NPT CBC hand written MAR chart Medicines Administration: Additional Information 42 Record 10. Incident Form Medication Error Glossary of Terms 44 5

6 1. Introduction This document outlines the roles, responsibilities and procedures for assisting service users with prescribed medication in the Community. It provides standards to be adopted and adhered to when assisting with medication which forms part of a service user s Personal Plan of Care. The National Service Framework for Older People (NSF) acknowledges the contribution of care workers to the daily living activities of older people living in their own homes and the considerable support in medicine taking. The NSF also acknowledges that ongoing education and training is essential for care workers in assisting with medication. The National Minimum Standards Domiciliary Care Agencies in Wales (Standard 10) states that care agencies have clear written policy and procedures which is adhered to by staff and which identifies parameters and circumstances for assisting with and health related tasks and identifies the limits to assistance and tasks which may not be undertaken without permission During the production of these guidelines, Care Workers have been crucial in identifying the problems that are currently experienced when they are assisting service users with medication. These guidelines were written in agreement with Neath Port Talbot Social Services Department, Neath Port Talbot Local Health Board, Bro Morgannwg Trust and Trade Union representatives from UNISON and GMB. Please note: References in the document to Care Workers mean paid employees supporting a service user in their own home i.e. those employed by social services or the independent sector. 2. Legislation and Statutory Requirements All tasks involving medicines are regulated by the Medicines Act 1968 and subsidiary regulations made under that Act. The policy and guidelines for Neath Port Talbot County Council Domiciliary Care Service embodies the principles of the NHS and Community Care Act 1990, National Care Standards Act 2000, The NHS Plan 2000, National Service Framework for Older People in Wales 2006, the Domiciliary Care Agencies (Wales) Regulations 2004 and the National Minimum Standards for Domiciliary Care Agencies in Wales (2004). In accordance with the guidance laid down in national standards, this document should be readily available to all staff and should be complied with at all times. It is the intention of Neath Port Talbot County Council Social Services, when purchasing services from independent care providers to share these guidelines with them. It will be a requirement that these standards be adopted thereby setting a uniformed standard of assisting across the Borough. 3. List of References The Handling of Medicines in Social Care Royal Pharmaceutical Society of GB (October 2007) Medicines Act

7 National Minimum Standards for Domiciliary Care Agencies in Wales (2004) National Service Framework for Older People in Wales 2006 National Care Standards Act 2000 The NHS Plan 2000 Domiciliary Care Agencies (Wales) Regulations PURPOSE AND SCOPE OF THE POLICY 4.1 Overall Aim The Social Services Department 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 medication. 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 unusual circumstances the specific needs of a service user needing assistance with medicines may fall outside of these guidelines e.g. with pain control. In these cases advice will be sought from Health Care Professionals. 4.2 Key Principles 1. Person centred care 2. To help people remain in or return to their own homes 3. To promote independence wherever possible 4. To accommodate personal and cultural preferences 5. To prevent avoidable admissions to hospital and care homes 6. To improve the quality of the service provided to people living in their own homes by continually monitoring the service provided 7. To define roles and responsibilities of front line Community workers in Neath Port Talbot 8. To ensure that any assistance given by care workers adheres to this policy 9. To ensure that assistance required is always defined in the Service Delivery Plan 10. To ensure that assistance may only be given by care workers who have received appropriate training and been approved as competent 11. Ownership of the policy rests with Neath Port Talbot Social Services 12. The Policy & Procedures Domiciliary Care Working Group will review the policy on a regular basis and in accordance with any legislative changes. 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 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 7

8 Privacy to have personal privacy and to have their property respected All Care Workers must be suitably trained and competent for the tasks they are asked to perform and Care Workers must feel confident to carry out these tasks correctly and safely. To ensure this, Care Workers 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. 5. Risk Management Assistance with medication will only be provided when there is no other means of the service user managing their own medication, 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. Medication 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 Care Workers must not carry out any invasive, clinical or nursing procedures, such as administering injections, enemas or pessaries (see Summary of Levels of Support page 21 & 22) Service Delivery Plan must be accessible in the service users home Completion of the Incident Form Medication Error (Appendix 10) which will identify an incident, will require the provider to carry out a risk assessment to eliminate or minimise the risk in future. 8

9 6. GENERAL PRINCIPLES OF GOOD PRACTICE IN ASSISTING PEOPLE WITH PRESCRIBED IN THE DOMICILIARY SETTING Everyone involved in the care of a service user is responsible for ensuring that his or her medication is managed appropriately where the service user is not self-medicating. However the primary responsibility for the prescription and medication 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 medication 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 on page 21-22). The service will be delivered in a way that enables self-determination and independence. Administration of medication will be delivered in a way that respects the dignity, privacy, cultural and religious beliefs of the service user. The National Minimum Standards for Domiciliary Care Agencies in Wales, Standard 10 - Medication and Health Related Activities will be adhered to. A copy of which is available in the line managers office. Care Workers will only provide help with taking medication, or administer medication, 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 Medication Consent Form (Appendix 1) Care Workers will only provide help with taking medication, or administer medication when it is requested by the Care Coordinator on the Plan of Care and documented on the Service Delivery 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 medication is part of a package of care. Care Workers should aim to ensure that service users receive appropriate help and encouragement to manage their own medication but where this is not safe, to ensure that they receive a suitable level of support and assistance with their medication as indicated in the Personal Plan of Care/Service Delivery Plan. It is acknowledged that Care Workers 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 medication to meet National Minimum Standards requirements and comply with best practice. New Care Workers will receive a full day of medication training during induction week. All other staff will receive a full one days training or two half day training sessions. 9

10 Ongoing competence will be achieved through NVQ II medication unit and supervisions. A competency assessment will be carried out annually. 7. Assessing the Needs of the Service User Service users will be allocated a care package following assessment under the Unified Assessment Process. A contact assessment will be completed by the relevant health or social care professional. Medication will be identified on this assessment and will include how the service user currently manages their medication. Once the service user has been assessed, the level of support needed with medication will be decided and added to the Unified Assessment Personal Plan of Care by the Care Coordinator. The Care Coordinator will ensure that the support required e.g. request for ordering or prescriptions, collection of medication from the Pharmacy, and the appropriate allocation of time for the care worker to administer medication is recorded on the Time Table of the Personal Plan of Care. If during the assessment by the Social Service team/ Healthcare team, or by the care provider, it is felt that a service user has difficulty with medication, but could manage his/her medicines if they were dispensed differently, the service user s usual Community Pharmacist may be able to help (see page 26). 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. The National Minimum Standards for Domiciliary Care Agencies in Wales (2004) states The agency s policies and procedures on medication and health related activities protect service users and assist them to maintain responsibility for their own medication and to remain in their own home. The policy and procedures for medication and health related activities are developed and agreed on a multi agency, multi disciplinary basis, taking into account all the clinical risks that could impact on the safety of the service user, the agency and health provider s accountability and responsibilities. In addition this process should include a suitably qualified Pharmacist in relation to medication. Where two or more providers are working with the service user, the Care Coordinator, in consultation with the two providers, will normally nominate the provider having most contact with the service user to take the lead role in medication management. The Care Provider responsible for the care package should ensure that patient consent has been obtained and recorded on the Personal Plan of Care and that where appropriate; a referral for provision of Medication Administer Record (MAR) chart has been completed and sent to the service users preferred participating Pharmacy. (See Appendix 2) At the stage of setting up a care package, family members must be made aware that they will be required to co-operate with Care Workers when they are carrying out specified tasks e.g. if a Care Worker needs to take a chart to the Pharmacy for updating, along with a prescription, then the family member should 10

11 not prevent this from happening. Family members/friends will be issued by the Care Provider with an information leaflet detailing their agreed responsibilities by the Care provider. (Appendix 3) 8. Levels of Medication Support Care Providers must ensure that training is provided and competency assessed for all Care Workers providing any level of support and that records of this training are kept. A Care Worker 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 medication 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 medication will only be provided where the service user has been assessed as being unable to administer their own medication (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 medication will only be provided with the consent of the service user, obtained when the Personal Plan of Care or the Service Delivery Plan is established or reviewed. The Consent Form (appendix 1) 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, then the current recommendations for treating adults with incapacity must be followed. These recommendations are subject to change. However, at the time of publishing these guidelines (2008) the recommendations found in the Mental Capacity Act (2005) should be adhered to. 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 f 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 conjunction with the Medicines Management Nurse. A referral to the Medicine Management Nurse for assistance will be via a completed Medicine Management Nurse Referral Form (Appendix 4). In addition Specialist Community Services such as ERS and Reablement may undertake this process within their caseload. However, all staff should be vigilant for changes in patient s needs. 11

12 Level A Support: The Service user requires no assistance with medication. Level B Support: 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 Care Worker 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 medication will be recorded in the Neath Port Talbot Medication Record Book on each visit. Dexterity/mobility: The service user manages his/ her own medicines, asking the Care Worker 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 medication 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 medication not within sight of the service user. In each of these scenarios, the service user, and NOT the Care Worker, retains sole responsibility for their medicine management and administration. The exact assistance given on each visit should be documented in the Neath Port Talbot Medication Record Book. Level C Support: The service user relies on the Care Worker to manage his/ her medicines. The Care Worker will be responsible for administering medication to the service user using a MAR chart provided (see example of MAR in appendix 5) 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 medication. 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. District Nurse and Domiciliary Care Provider, 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 Delivery Plan. 8.1 Understanding Level A Support Level A service users take full responsibility for their own medicines and require no assistance with medication from the Care Worker. 12

13 It is important to remember that the ability of the service user may change and that the Care Worker is often the only person who will be aware of these changes. If the Care Worker identifies any changes in the ability of a service user to manage his/ her own medicines, this should be reported to the Care Worker s line manager as soon as possible. 8.2 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 personal plan of care. Any requests for further help must be reported as soon as possible to the Care Worker 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 Care Worker s line manager and written into the Service Delivery Plan. The Care Coordinator has the responsibility of recording all permanent changes to the Personal Plan of Care on the service user s data base held on the IT system. Important information for Care Workers providing Level B Support Request for further help Care Workers must only give assistance with the tasks documented in the personal plan of care. Any request for further assistance must be reported to the Care Worker s line manager as soon as possible. Filling pill boxes for the service user Care Workers must never help the service user by filling compliance aids (these are boxes with compartments for morning, lunchtime, teatime and bedtime). Care Workers 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. For service users categorised as Level C (page 15), Care Workers can NOT assist service users to access MDS that has been filled by family member or friend. Giving Advice Care Workers 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 Care Workers must continually assess whether service users are still capable of managing their own medicines. For example: 1. Is the service user confused about when to take his/ her medicines? 2. Is the service user running out of medicines regularly or have too many left? 3. 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 medication must be reported to the Care Worker 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, District Nurse and Pharmacist. 13

14 If however, the Care Worker feels that the service user needs emergency medical help, then the Care Worker 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 medication, the Care Worker should advise the service user to check the labels on the medication 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 Care Worker 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 Care Worker (following advice from his/her line Manager) may assist the service user to do this. The service user must be capable of directing the Care Worker and remains responsible for specifying the medicine to be ordered and the dosage and quantity to be requested. Any assistance given should be recorded in the Medication Record Book. Different surgeries will have different procedures for ordering repeat prescriptions and therefore the service user should inform the Care Worker 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 Care Workers 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 - page 26). 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 Care Worker should be carried out by his/her line manager, and if it is felt appropriate, the Care Worker may then be asked to collect medicines on behalf of the service user. This must be clearly noted in the Personal Plan of Care and the Delivery Support Plan. Opening Containers Should the service user have difficulty opening medicine containers then the Care Worker may give assistance, if requested to do so, and this task is stated in the Service Delivery Plan. This may involve taking the top from medicine bottles, 14

15 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 Care Worker will only be responsible for opening a container at the request of the service user, not prompting him/ her to take or use medication. However, please note that the patient s Community Pharmacy may be able to help by dispensing medicines in easy open containers. Disposal of Unwanted Medicines If an appropriate waste licence is acquired then Care Workers are able to return medications. 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 Care Workers are able to remove medicines from a service user s home and return to a Pharmacy for disposal. However, before a Care Worker 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 (Appendix 6). On return of the medicines to the Pharmacy, the Pharmacist must sign the Medicine Disposal Form, which will be returned to the Care Worker and then stored by the care provider 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, the Provider will contact the Medication Management Nurse for a risk assessment and a review to be undertaken. 8.4 Understanding Level C Support Service users at Level C have been assessed as being unable to manage their own medicines and as requiring the Care Worker to assist with and be responsible for their medication. 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 Care Worker in the process of medication 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 Care Worker remains responsible for selecting and administering the appropriate medications as per the instruction on the medication label and as per the MAR chart. Important Information for Care Workers providing Level C Support Administering Medicines to service users Care Workers can assist service users with their medication, provided they have been appropriately trained, that the medicine has been prescribed and the 15

16 written directions of the prescriber are followed. These directions will be on the medicine label and the MAR chart. Care Workers can give or assist people in: Taking tablets, capsules, oral mixtures Inserting drops to ear, nose or eye Administering inhaled medication Apply a medicated cream/ointment to skin that is unbroken. Care Workers should NOT apply medicated cream/ointment to broken skin/lesions/wounds. Administering medicines to service users requiring Level C support Each time a Care Worker administers a medicine to the service user the procedure for administration of medications must be followed. (Appendix 7) Care Workers can only give assistance with medicines if the tasks have been written into the Service Delivery Plan, a copy of which will be kept in the service user s home. Medication can only be given to the service user if it has been written onto a MAR chart. The use of Medication Administration Record (MAR) Charts The Care Coordinator/Care Provider/Medicine Management Nurse who assesses the person 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, (Appendix 2) and a copy sent to the Medicines Management Nurse and Care Provider. The Care Coordinator may request the Care Provider to carry out this task on his/her behalf. Where there is a delay in acquiring a MAR chart from a participating Community Pharmacy, a hand written NPT Social Service chart may be completed and used for no more than four working days (Appendix 8). Completion will be by the provider service/medicine Management Nurse and MUST be checked by a second individual, signed and dated. If this occurs, it should be recorded in the Delivery Plan of Care. The MAR Chart will be 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 Care Workers must be aware of these details. All Care Workers must complete the MAR Chart when assisting with medication and the Care Provider will be responsible for removing this at the end of each month and replacing it with a new sheet. The Care Provider 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 medication is prescribed and the old MAR chart should be removed. These sheets must be stored by the care provider 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. 16

17 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 (Appendix 9) which will be with the MAR chart. Where a Care Worker finds that this has occurred and they are therefore unable to place their initials in the appropriate box when administering the medication, they should instead document and sign that they have administered the medication 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 Care Workers 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 (see page 18) 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 Management Nurse to 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 Care Workers. The Medicine Management Nurse will review these service users at a minimum of 3 monthly intervals. Where Warfarin is assessed as complex/unstable, the Care Workers will NOT administer and other arrangements will be negotiated with Health. Shared Care If more than one Care Provider is responsible for assisting the service user with medication, then the person setting up the care package must designate a Lead Provider (usually the Provider giving most support with medication). This Care Provider will be responsible for ensuring new MAR Charts are in place, and storing completed MAR charts. Care Workers from both provider service will use the same MAR chart when assisting with medication. Each Care Provider will be responsible for the actions of their own care staff. When required 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. 17

18 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. (See storage page 20) 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. During the transitional period, there may be circumstances where Care Workers will administer from MDS until a MAR chart is established. Where this is the case, it will be recorded in the Neath Port Talbot Record Book (Red Book), and recorded as Medication dispensed from MDS and signed and dated by the Care Worker. Medicines For Later (4 later) 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 Medicine Management Nurse as appropriate, agreed with the service user, and it is documented in the Service Delivery Plan. Doses administered 4 later are recorded on the MAR with the number 4 instead of the Care Worker s initials. The next Care Worker 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 Care Worker must dispose of them as they would for any refused (see Disposal of refused medication below), and this should be recorded on the Medicines Administration: Additional Information Record. Keeping a record of the initials and signatures of all Care Workers A record of the printed names, signatures and initials of all Care Workers must be kept by Care Providers. This is extremely important when Care Workers are initialling MAR charts. Service users refusing The Care Worker must never force a service user to take medication. If a service user refuses the Care Worker 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 Care Worker seeks advice from the Pharmacist either directly or via the Care Worker s line manager. Any advice given will be recorded. This does not apply to medicines which are taken only when required. Disposal of refused If the service user refuses to take medication before it has been taken from the packaging, then the medicine will be kept in the package and the Care Worker 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 Care Worker should sign for this action. At the end of the month the person responsible for collecting new medication (family or Care Worker) from the Community Pharmacy should return the refused medicines to the Pharmacy, having completed the Medication Disposal Form (Appendix 6) and a new bottle obtained. 18

19 Service users who have consumed alcohol Care Workers giving Level C support must not give medication 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 Care Worker 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 Medication is not given Medication is given to the wrong service user Medication 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 Care Worker s competency and provide additional training where appropriate. Repeated errors despite additional support may lead to alteration of duties. All errors and near misses must be reported by completing an Incident Form Medication Error (see appendix 10) which is forwarded to the Medicine Management Nurse 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 should be reported to the regulatory body. Care Workers 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 Care Worker 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 Care Provider will highlight on the Service Delivery Plan that 5 days prior to the MAR chart expiry date, the Care Worker will order a repeat medication and MAR chart from the GP/Community Pharmacist 19

20 Collecting Prescriptions from the surgery and Collecting Medicines from the Pharmacy same procedure as for Level B (page 13) Storage of medicines Care Workers 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 Medicine Management Nurse. In this situation the location of the medicines should be documented in the Service Delivery Plan and written consent 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 medications 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 medications, then this should be discussed with the prescriber. Such medications include; reliever inhalers (such as salbutamol), glyceryl trinitrate spray (GTN spray). Disposal of medicines the same procedure as for a service user under category B (page 15) Insurance It is important that Care Providers have adequate insurance for all the tasks relating to medicine administration that they ask Care Workers to carry out. Complex Regimes For those service user who are prescribed more than 8 (eight) different types of medicines, the Provider will contact the Medicine Management Nurse for a risk assessment and a review to be undertaken. 20

21 8.4 Summary of Levels of Support Care Workers CAN/MUST Care Workers WILL NOT Level A Monitor level of independence/capability is maintained & inform line manager of any relevant change. Assist/ remind/be involved in management in any way. Level B Monitor level of independence/capability is maintained & inform line manager of any relevant change. Inform line manager of requests for further help than is documented in the Delivery Plan Remind service user to take their medication. Manipulate packaging under direction and in full view of service user Assist in ordering/collection of medications as directed by service user Under full direction of service user, place into service user s mouth/ear/eye/nose Must document all assistance given in NPT Medication Record Book on each visit Report mistakes as soon as possible May assist to access medication from a compliance aide which has been filled by family members. Assist in any way that is not clearly documented in the Delivery Plan and written consent obtained. Assist with medications out of sight of the service user Fill compliance aids Read out instructions etc on packaging for service users Offer advice or recommendations regarding medication Take direction from service user s family or friends regarding medications/ordering/collection Must not administer injections/suppositories/pessaries/enemas force or coerce the service user to take medication Crush tablets or open capsules Undertake any medication task that they do not feel adequately competent to undertake 21

22 Care Workers CAN/MUST Care Workers WILL NOT Level C Monitor level of independence/capability is maintained & inform line manager of any relevant change Inform line manager of requests for further help that is not documented in Delivery Plan Administer medication using MAR chart or MDS as per policy and procedure Must document administration given on Pharmacy Printed MAR chart and record any other information on the Additional Information Record sheet (Appendix 9) Ensure safe storage of Medication Seek advice from line manager where the service user refuses medication Place refused medication already removed from original container into refused bottle and return to Pharmacy Assist in any way that is not clearly documented in the Delivery Plan and written consent obtained Fill compliance aids or use compliance aids which have not been dispensed by Community Pharmacist Must not administer injections/suppositories/pessaries/enemas Offer advice or recommendations regarding medication Force or coerce the SU to take medications Crush tablets or open capsules Replace refused medication into its original container Undertake any medication task that they do not feel adequately competent to undertake Leave out medicines for the service user to take later UNLESS it is clearly stated in the Service Delivery Plan as 4 later Give any medication that is not recorded on the MAR chart including over the counter Amend/alter the MAR chart in any way Report mistakes as soon as possible Only undertake tasks that they feel adequately competent to undertake 22