MEDICATION POLICY FOR DOMICILIARY CARE

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

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Domiciliary Setting Medicines Management (Domiciliary Care) Steering Group Review Date: For use by: For information by: Superseded Documents: Timing: Contact details: November 2008 and thereafter annually.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

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

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

Contents Section Title Page 1 Introduction 5 2 Legislation and Statutory Requirements 6 3 List of References 6 4 Purpose and Scope 7 4.1 Overall Aim 7 4.2 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 11 8.1 Understanding Level A Support 12 8.2 Understanding Level B Support 13 8.3 Understanding Level C Support 15 8.4 Summary of Levels of Support 21 9 Roles and Responsibilities 23 9.1 Care Coordinator 23 9.2 Medicines Management Nurse 23 9.3 Care Provider 24 9.4 Care Worker 25 9.5 District Nurse 25 9.6 Specialist Nurse 25 9.7 Specialist Community Services 25 9.8 Community Pharmacist 26 10 Policy Dissemination 27 11 Appendices 1. Consent Form 28 2. Referral to Pharmacist for Provision Of MAR Chart 29 3. Leaflet for Relatives/Friends 30 4. Medication Management Nurse Referral Form 32 5. MAR Chart 33 6. Medication Disposal Form 34 7. Guidelines and Procedure for the Safe Administration 35 And Management of Medicines 8. NPT CBC hand written MAR chart 41 9. Medicines Administration: Additional Information 42 Record 10. Incident Form Medication Error 43 12 Glossary of Terms 44 5

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 1968 6

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 2004 4. 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

9. Roles & Responsibilities All parties outlined below are responsible for working in partnership and in concordance with the policy and procedure as set out in this document, and may be asked to contribute to/cooperate with measuring outcomes, auditing and monitoring processes for medicines management undertaken by the Medicines Management Nurse. 9.1 Role & Responsibilities of the Care Coordinator The role of the Care Coordinator as related to domiciliary care is pivotal in ensuring that service users receive the appropriate level of assistance they require with the administration of medication. The Care Coordinator must ensure that: All service users are subject to an assessment of their ability to manage their own medication. This can be achieved through a multidisciplinary assessment involving the family, carers or members of the primary healthcare team as appropriate. This assessment will be made available to the service providers. A record is made of any judgement arrived at by the multidisciplinary team. The details must also be recorded on the Personal Plan of Care. Accurate information must be available regarding the level of assistance required and this will be shared with the service provider. Where it is available this could include information about the name, dosage and frequency of medication. The Care Coordinator must be advised to check with the service user s Pharmacist, GP (or hospital if an inpatient) to clarify the current medical situation. As part of arranging a package of care, the Care Coordinator can refer to the Medicine Management Nurse for an assessment for the provision of a MAR chart. In accordance with the Personal Plan of Care, the arrangements for assistance with administration of medication is reviewed. Reviews will take place in line with standard review policy and be conducted using feedback from care staff and their line managers. This will be within the first 3 months of a new Service Delivery Plan and thereafter annually unless a change of Social Care circumstances requires a reassessment. 9.2 Roles and Responsibilities of Medicines Management Nurse Many service users may have the potential to independently manage their medications, in part or in full, and all efforts should be made to enable this process to ensure their safety, dignity and autonomy are preserved at all times. Where such potential is identified, a referral to the Medicines Management Nurse should be considered. The Medicine Management Nurse will: Take a clinical leadership role across Health and Social Care to improve medicines management, promote independence and improve care outcomes for older and disabled people receiving Homecare in Neath Port Talbot. Carry out a risk assessment on all service users who are prescribed Warfarin. 23

Lead on development and delivery of the established training programme in collaboration with the training department for care staff and managers with respect to medicines management. Manage a defined caseload of clients with highly complex multi-agency needs within the domiciliary care setting to assess, plan, implement and evaluate interventions in their medicines management, maintaining associated records. In partnership with the service user and family/carers, the Medicine Management Nurse will identify a plan of action to improve their independence with their medication management. This may involve undertaking a number of interventions including further assessments, giving advice/education regarding techniques and strategies, or helping the service user to access appropriate equipment/aids. Work in partnership with all health and social care professionals concerned to ensure that these identified needs are met and maintained, and will act as a resource to such colleagues who may seek advice regarding promoting independence with medicines management. Lead on developing and monitoring mechanisms for outcome measurements, auditing and monitoring processes to ensure best practice and adherence to policies and procedures with respect to medicines management in the domiciliary care setting. 9.3 Roles and Responsibilities of the Care Provider 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 Care Workers are provided with information, instructions and training which enables them to competently carry out their duties as described in these guidelines. Training must be updated regularly to ensure competency. To ensure Care Workers are competent to carry out tasks as specified in the Service Delivery Plan through supervision and monitoring. To ensure Care Workers are not undertaking inappropriate tasks. To liaise with care management to ensure that the Service Delivery Plan accurately describes the support the Care Worker is being asked to provide. To liaise with the medicines management nurse regarding queries and other healthcare professionals as appropriate (e.g. GPs, District 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 Medicine management Nurse for provision of a MAR chart. 24

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. 9.4 Roles and Responsibilities of the Care Worker To follow the procedure when administering medication. The role of the Care Worker 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. Care Workers must notify their line manager where they are being asked to provide assistance with medication which deviates from this guidance. Care Workers must not provide advice regarding medication. They must seek clarification and guidance from their line manager if queries arise. Care Workers must adhere to this policy and procedure at all times. Care Workers must not apply antiseptic cream ointment to broken skin lesions If in doubt medication must not be given and advice sought. 9.5 Role of the District Nurse The District Nurse will have a major input into the care of many service users and the Care Worker must therefore work closely with the District Nurse. The District Nurse will provide an effective link with the service user s GP. The District Nurse will, where appropriate, provide specialist training for Care Workers and is a good source of advice for Care Workers regarding the care and well being of the service user. 9.6 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 Care Workers to work closely with these nurses. 9.7 Role of Specialist Community Services Medication issues may be identified and assessed by specialist services such as Early Response Service and NPT Reablement. Such services may undertake the process of safely moving service users within their caseload up or down levels of support, facilitated by the Medicine Management Nurse 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 Medication 25

Management Nurse, and the service will ensure effective communication with care providers 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 the Medicines Management Nurse. 9.8 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. 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 Pharmacist now offer a service whereby repeat prescription from the GP is sent to the Pharmacist who then deliver the medication to the service user. If the Pharmacy has a Waste Disposal Licence, they will be able to pick up and dispose of unwanted medication. 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 medication 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 Care Worker 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 medication. 26

The Community Pharmacist is a readily accessible source of support for staff and may be able to assist them in managing service user s medication 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 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 Care Workers providing Level C support Pharmacies will have a practice leaflet available to customers describing the range of services they offer. 10. POLICY DISSEMINATION All new employees will be made aware of this policy and medication procedures as part of the induction process and existing employees at Care Workers team meetings. All employees involved in administering medication must have received relevant training and have been formally assessed as competent by their line manager/trained trainer. Competence in dealing with medication must be assessed and recorded via annual monitoring. Registered Managers are responsible for ensuring compliance with this policy. Compliance will be assessed through monitoring, supervision, regular audit of Service Delivery Plans and documentation regarding medication. 27

APPENDIX 1 CONSENT FORM I give my consent to the Care Workers to assist me with administering medication in accordance with my Service Delivery Plan. I also agree that arrangements for appropriate storage of my medication is made. This may require: A suitable container/box with a lid. A lockable box which I will not have access for my own safety and well being. (Delete as applicable) I also give my consent for the care provider(s) to share relevant information about my care or well being with appropriate health/social care professionals. Name of Service User: Address:... Service User signature:. Date:. Signature of person signing on behalf of the service user:. Date:. Signature of Person gaining consent:. Date:. A copy of this form must be kept in the service users records by all agencies provider assistance with medication. A copy of this form must be kept in the Service User s records by all agencies providing assistance with medication. 28

Appendix2 Referral to Community Pharmacist for provision of Medication Administration Record (MAR) Charts for Patients receiving Domiciliary Care in Neath Port Talbot Name of Service User Tel: D.O.B. Address of Service User: Times of care calls. Provider: Name of Manager/Supervisor: Tel: GP Name: Address Tel: Name of Pharmacy: Address (NB. Must be a participating in the NPT MAR scheme.) Tel: Referred by: Name: Signature: Designation: Date MAR to start Any allergies Date: To be faxed/sent to Service User s Community Pharmacist. Additional Copies to be faxed/sent to: Medicines Management Nurse: Home Care Offices, New Neath Civic, Neath SA11 3QZ fax no. 01639 764413 Care Provider NB: Patient/patient representative has consented to the domiciliary care plan, including arrangements for assistance and sharing of relevant information. 29

Appendix 3 IMPORTANT INFORMATION ABOUT YOUR RELATIVE/FRIEND S MEDICATION WHO HAS BEEN ASSESSED AS REQUIERING A MAR CHART Useful Phone Numbers Provider Service Manager. GP. Community Pharmacist.. 30

Important information about your relative/friends Your relative/friend is receiving help with their medication from a care worker. The help they receive has been designed to meet their needs whilst promoting their independence. This information is important to maintain the wellbeing and safety of your relative/friend. Please take some time to familiarise yourself with the following points: Unless specifically arranged with the Provider Manager, it is assumed that you will not be involved in administering medication to your relative/friend A Medication Administration Record (MAR) chart will be provided every month by your relative/friend s Community Pharmacy. This will list all prescribed medication and when it must be administered The medication needs of your relative/friend are being looked after by their care worker. The care worker will initial the MAR chart every time they administer medication to your relative/friend. If a circumstance arises where you feel it is necessary to administer medication to your relative/friend, contact the Provider Manager to inform them and sign the MAR chart. This will ensure your relative/friend receives the correct amount of medication. Purchased medicines (from supermarket / Chemist etc) including herbal remedies and other alternative remedies may interact with your relative/friend s medication. Please discuss these types of medicines with your relatives/friends Community Pharmacist before giving them to your relative/friend. Medication will be kept in a box/container with a lid, sometimes it is kept in a locked box to ensure the safety of your relative/friend. If you have any queries or problems please contact the Provider Manager 31

Appendix 4 CONFIDENTIAL MEDICATION MANAGEMENT NURSE REFERRAL FORM Tel 01639 764153, Mobile 07816999017, Fax 01639 764413 REFERRAL FORM COMPLETED BY: POSITION: TELEPHONE NO: EMAIL ADDRESS: DATE OF REFERRAL: NAME OF SERVICE USER: D.O.B. ADDRESS: TEL. NO: HAS SERVICE USER GIVEN CONSENT FOR REFERRAL? (please circle) YES NO GP NAME: GP TEL. NO: GP ADDRESS: COMMUNITY PHARMACIST: TEL NO: PHARMACY ADDRESS: CARE MANAGER: CARE MANAGER TEL. NO: REASON FOR REFERRAL: Please include issues from Unified Assessment and/or any other relevant information, e.g. recent discharge from hospital MEDICATION: Please attach repeat prescription info. (Can by obtained via GP surgery and faxed to 01639 764413) If not attached please state reason, e.g. GP not willing etc. Please circle if attached: YES NO Please state what care the service user currently receives, i.e. when receiving care and frequency. Please state whether it would be appropriate for next of kin to be present. If so, give details. 32

Appendix 5 33

Appendix 6 RECORD OF MEDICATION RETURNED TO PHARMACY FOR DISPOSAL This form must always be completed when a Home Care Worker is returning a service user s unwanted or discontinued medicines to a Pharmacy for destruction Name of service user: Address: Complete Box 1 or 2 which ever is appropriate Box 1 DATE MIXTURE OF REFUSED MEDICATION YES/ NO REASON FOR RETURN Box 2 DATE MEDICATION (Name and strength) OR QUANTITY (if known) REASON FOR RETURN (e.g. out of date) I understand that some of my medicines are out of date or are no longer needed by me. I allow my care assistant to remove these medicines and I understand that he / she will dispose of them at the Pharmacy on my behalf. SIGNATURE OF SERVICE USER SIGNATURE OF CARE ASSISTANT DATE For completion by the Community Pharmacy I.. confirm receipt of the medicines listed above, which have been returned to me for safe destruction. Signature of Community Pharmacist/ Technician:.. Date:.. Pharmacy Stamp 34

Appendix 7 Guidelines and Procedure for the Safe Administration and Management of Medicines 1. INTRODUCTION 1.1 This 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 Care Worker. 1.3 This procedure must be followed when Care Workers 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 Service Delivery Plan as a level B or C 2. OBTAINING PRESCRIPTIONS AND DISPENSED 2.1 Obtaining prescriptions If the personal plan of care requires a repeat prescription to be ordered, the Care Provider will indicate on the Service Delivery Plan that 5 days prior to expiry of the MAR chart, the Care Worker is to order /MAR chart from the GP/Pharmacist. Care Worker must not over order or stockpile. The Care Worker: 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 the Care Worker 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 Care Workers) 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 Service Delivery 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 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 Care Worker should check that there is enough to last for the next few days and to order medicines as agreed in the Service Delivery Plan. All unused regular and refused medication should be returned to 35

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 Care Worker 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 Medicine Management Nurse 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 Provider service to supply locked boxes (standard 10.6 of the National Minimum Standard). 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 Service Delivery 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 36

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 Care Worker s initials. The next Care Worker 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 Care Worker 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. 37

Medication Administration Procedure Level B administration: Reminding 1. Introduce yourself to the service user 2. Check the Service Delivery Plan for instructions on medication 3. Remind the service user to take their medications and observe that they carry this out. 4. The exact assistance given on each visit should be documented in the Neath Port Talbot Medication Record Book. Assisting 1. Introduce yourself to the service user 2. Check the Service Delivery Plan for instructions on 3. Discuss with the service user their medication requirements. 4. Taking directions from and in the full view of the service user, give assistance to the service user as requested by them. 5. Ensure that the service user is able to remain in control of their own medication. 6. The exact assistance given on each visit should be documented in the Neath Port Talbot Medication Record book. 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) 1. Introduce yourself to the service user 2. 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 3. Check Service Delivery Plan for instructions on medication 4. Choose the appropriate compartment, remove tablets and give to the service user to take. Record medication given from dosette box in the NPT Medication Record Book. There will be no requirement for a MAR chart Level C administration using a MAR Chart and original containers 1. Introduce yourself to the service user 2. 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 3. Check Service Delivery Plan for instructions on medication 4. Explain that you will need to check the medication to see if any is to be given prior to food. 5. Find a clean area free from clutter 6. 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 38

medicines have been taken already STOP PROCEDURE and inform line manager. Other wise continue as follows: 7. Remove all medicines from the box, checking as you do that they all have the service user s name on them. 8. Assemble all of the equipment needed to administer the medication such as 5ml spoon, MAR chart,, gloves etc. 9. 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 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. 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 line 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) Wash and dry hands and put on gloves 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. 39

10. 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. 11. 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. 12. Wash and dry hands and put on gloves 13. 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. 14. 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 Care Worker 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 Care Worker seeks advice from the Pharmacist either directly or via the Care Worker s line manager. Any advice given will be recorded. 1. 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) 2. If medication has not been removed from the original container then leave in place. 3. 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. 4. All changes in the service user s condition including refusal of regular medication should always be reported to Service users 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. 40

Appendix 8 March 2008 41

Appendix 9 Medicines Administration: Additional Information Record Service user Date of birth Date Comments Signature March 2008 42

Appendix 10 Incident Form Medication Error Forward to Medicines Management Nurse, Fax 01639 764413 Date incident reported Date incident occurred Name of service user Address Details of incident What do you think went wrong & why? (e.g. were there any distractions?) Action taken (e.g. GP contacted) Outcome of action (e.g. followed advice give from GP) Action taken as a result of error (e.g. further training, clarification of procedure etc) Overall outcome (e.g. health of service user, CSIW informed etc) Name & Position Signature Date March 2008 43

12. GLOSSARY OF TERMS ADMINSTER Legally defined as Whether orally, by injection or by introduction into the body in any other way, or by external application, a substance or article either in its existing state or after it has been dissolved or dispersed in, or diluted or mixed with, some other substance used as a vehicle. However in practice it is not possible to distinguish between administer and assist regarding medication. These words may be used interchangeably. APPROVED TRAINING This is a structured programme of training that has been agreed between health and social services. Social service or private provider employees involved in managing service users medication will be assessed regarding their competency to undertake specific tasks and then judged competent to do so. ASSIST In practice it is not possible to distinguish between administer and assist regarding medication. These words may be used interchangeably. CARE COORDINATOR A term used in this document for a Social Worker (Care Manager) or a Care Manager Assistant CARE WORKER A person who provides direct services to a service user and is employed by Neath Port Talbot County Borough Council or one of its contractors. CARE MANAGEMENT Is the process of tailoring services to meet individual needs following a holistic assessment and Service Delivery Planning by the Care Manager. CARE MANAGER Is a professional representative of Neath Port Talbot County Borough Council who assesses the needs of a service user, plans and arranges delivery of services required to meet those needs. DELIVERY PLANNING Means negotiating the most appropriate ways of achieving the objectives identified via an assessment of need and incorporating them into an individual Service Delivery Plan. CONTAINER Blister pack, bottle or any other container that the Pharmacist deems suitable (e.g. Monitored Dosage System). A Pharmacist must supply medicines in childproof containers unless specifically requested not to do so by the service user, or the medicine is such that it must remain in the manufacturer s original special container which is not childproof. CONTRACT An agreement, usually in written form between a purchaser and a provider for the provision of services, over a specific period at an agreed cost. CONTRACTOR Shall mean the person or persons who are responsible for providing the services to a service user, in accordance with the specifications and conditions of the contract. For example, private providers are contractors to Neath Port Talbot County Borough Council. March 2008 44

DRUG The terms drug, medicine and medication are used interchangeably. INFORMATION FILE File that remains in the service users home documenting the Service Delivery Plan, communications etc. MAR CHART Medication Administration Record (MAR). Used for recording administration, refusal and 4 later. MEDICATION The terms drug, medicine and medication are used interchangeably. MEDICINE The terms drug, medicine and medication are used interchangeably MONITORED DOSAGE SYSTEM (MDS) A system or device which separates different doses, and is used as an aid to compliance. It must be prepared by a Pharmacist. It is only suitable for certain drugs and certain service users. NEATH PORT TALBOT COUNTY BOROUGH COUNCIL The elected body responsible to the central government for the provision of a range of services within the county. ORIGINAL PACK Package supplied by Pharmacy containing medication. This may be an original container from manufacturer or medication may be packed down by the Pharmacy from a stock supply into a smaller container. The original pack will be labelled with the patients name, date of supply, name of medicine, strength of medicine, form of medicine, quantity of medicine and the name and address of supplying Pharmacy. PERSONAL PLAN OF CARE A record that sets out, for people who are to be provided with help, the objectives of that help, preferred outcomes, services to be provided, a review date and other details. PROVIDER Either the Neath Port Talbot CBC Homecare service or an Independent (Private) Provider providing a service at an agreed cost. REGISTERED MANAGER May be Provider Manager in Social Services or Registered Manager in the Independent Provider sector. REVIEW Refers to a reassessment of people s needs and issues and consideration of the extent to which services are meeting the stated objectives and helping to achieve the described outcomes. SERVICE USER Refers to a person who is in receipt of a Health or Social Care Services. March 2008 45