Managing medicines for adults receiving social care in the community

National Institute for Health and Care Excellence


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Governance for managing medicines safely and effectively

  • Health and social care commissioners and providers should review their local governance arrangements to ensure that it is clear who is accountable and responsible for providing medicines support
  • When social care providers have responsibilities for medicines support, they should have a documented medicines policy based on current legislation and best available evidence. The content of this policy will depend on the responsibilities of the social care provider, but it is likely to include processes for:
    • assessing a person's medicines support needs
    • supporting people to take their medicines, including 'when required' ,time-sensitive and over-the-counter medicines
    • joint working with other health and social care providers
    • sharing information about a person's medicines
    • ensuring that records are accurate and up to date
    • managing concerns about medicines, including medicines-related safeguarding incidents
    • giving medicines to people without their knowledge (covert administration)
    • ordering and supplying medicines
    • transporting, storing and disposing of medicines
    • medicines-related staff training and assessment of competency

Assessing and reviewing a person's medicines support needs

  • Many people want to actively participate in their own care. Enabling and supporting people to manage their medicines is an essential part of this, with help from family members or carers if needed. The term 'medicines support' is defined as any support that enables a person to manage their medicines. This varies for different people depending on their specific needs
  • Assess a person's medicines support needs as part of the overall assessment of their needs and preferences for care and treatment
  • Do not take responsibility for managing a person's medicines unless the overall assessment indicates the need to do so, and this has been agreed as part of local governance arrangements
  • Ensure that people assessing a person's medicines support needs (for example, social workers) have the necessary knowledge, skills and experience
  • Engage with the person (and their family members or carers if this has been agreed with the person) when assessing a person's medicines support needs. Focus on how the person can be supported to manage their own medicines, taking into account:
    • the person's needs and preferences, including their social, cultural, emotional, religious and spiritual needs
    • the person's expectations for confidentiality and advance care planning
    • the person's understanding of why they are taking their medicines
    • what they are able to do and what support is needed, for example, reading medicine labels, using inhalers or applying creams
    • how they currently manage their medicines, for example, how they order, store and take their medicines
    • whether they have any problems taking their medicines, particularly if they are taking multiple medicines
    • whether they have nutritional and hydration needs, including the need for nutritional supplements or parenteral nutrition
    • who to contact about their medicines (ideally the person themselves, if they choose to and are able to, or a family member, carer or care coordinator)
    • the time and resources likely to be needed
  • Record the discussions and decisions about the person's medicines support needs. If the person needs medicines support include the following information in the provider's care plan:
    • the person's needs and preferences
    • the person's expectations for confidentiality and advance care planning
    • how consent for decisions about medicines will be sought
    • details of who to contact about their medicines (the person or a named contact)
    • what support is needed for each medicine
    • how the medicines support will be given
    • who will be responsible for providing medicines support, particularly when it is agreed that more than one care provider is involved
    • when the medicines support will be reviewed, for example, after 6 weeks
  • Review a person's medicines support to check whether it is meeting their needs and preferences. This should be carried out at the time specified in the provider's care plan or sooner if there are changes in the person's circumstances, such as:
    • changes to their medicines regimen
    • a concern is raised
    • a hospital admission
    • a life event, such as a bereavement

Joint working between health and social care

  • Joint working enables people to receive integrated, person-centred support. Health professionals working in primary and secondary care have an important role in advising and supporting care workers and other social care practitioners
  • Social care providers should notify a person's general practice and supplying pharmacy when starting to provide medicines support, including details of who to contact about their medicines (the person or a named contact)
  • General practices should record details of the person's medicines support and who to contact about their medicines (the person or a named contact) in their medical record, when notified that a person is receiving medicines support from a social care provider
  • Social care practitioners should seek advice about medicines from people with specialist experience, such as the prescriber, a pharmacist or another health professional, when it is needed
  • Health professionals should provide ongoing advice and support about a person's medicines and check if any changes or extra support may be helpful, for example, by checking if:
    • the person's medicines regimen can be simplified
    • information about time-sensitive medicines has been shared
    • any medicines can be stopped
    • the formulation of a medicine can be changed
    • support can be provided for problems with medicines adherence
    • a review of the person's medicines may be needed
  • When specific skills are needed to give a medicine (for example, using a percutaneous endoscopic gastrostomy [PEG] tube), health professionals should only delegate the task of giving the medicine to a care worker when:
    • there is local agreement between health and social care that this support will be provided by a care worker
    • the person (or their family member or carer if they have lasting power of attorney) has given their consent
    • the responsibilities of each person are agreed and recorded
    • the care worker is trained and assessed as competent (see also the section on training and competency)
  • Health professionals should continue to monitor and evaluate the safety and effectiveness of a person's medicines when medicines support is provided by a care worker

Sharing information about a person's medicines

  • It is important that information about medicines is shared with the person and their family members or carers, and between health and social care practitioners, to support high-quality care
  • For guidance on medicines-related communication and medicines reconciliation when a person is transferred from one care setting to another, see the NICE guideline on medicines optimisation
  • When social care providers have responsibilities for medicines support, they should have robust processes for communicating and sharing information about a person's medicines that take account of the person's expectations for confidentiality. This includes communication with:
    • the person and their family members or carers
    • care workers and other social care practitioners
    • health professionals, for example, the person's GP or supplying pharmacist
    • other agencies, for example, when care is shared or the person moves between care settings
  • If a person has cognitive decline or fluctuating mental capacity, ensure that the person and their family members or carers are actively involved in discussions and decision-making. Record the person's views and preferences to help make decisions in the person's best interest if they lack capacity to make decisions in the future
  • Follow the advice on sharing information about medicines when a person is transferred from one care setting to another in the NICE guideline on medicines optimisation
  • Prescribers should communicate changes to a person's medicines (for example, when stopping or starting a medicine) by:
    • informing the person or their named contact and
    • providing written instructions of the change or issuing a new prescription and
    • informing the person's supplying pharmacy, if this is needed and agreed with the person and/or their family members or carers
  • When changes to a person's medicines need to be made verbally to avoid delays in treatment (for example, by telephone, video link or online), prescribers should give written confirmation as soon as possible. Written confirmation should be sent by an agreed method, for example, a secure fax or secure email
  • When social care providers have responsibilities for medicines support, they should have robust processes for handling changes to a person's medicines received verbally from a prescriber, including:
    • recording details of the requested change (including who requested the change, the date and time of the request, and who received the request)
    • reading back the information that has been recorded to the prescriber requesting the change to confirm it is correct (including spelling the name of the medicine)
    • asking the prescriber requesting the change to repeat the request to someone else (for example, to the person and/or a family member or carer) whenever possible

Ensuring that records are accurate and up to date

  • Poor record keeping can put people receiving medicines support and care workers at risk. Social care providers are required by law (The Health and Social Care Act 2008 [Regulated Activities] Regulations 2014) to securely maintain accurate and up-to-date records about medicines for each person receiving medicines support
  • When social care providers have responsibilities formedicines support, they should have robust processes for recording a person's current medicines. These should ensure that records are:
    • accurate and kept up to date
    • accessible, in line with the person's expectations for confidentiality
  • Care workers must record the medicines support given to a person for each individual medicine on every occasion, in line with Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This includes details of all support for prescribed and over-the-counter medicines, such as:
    • reminding a person to take their medicine
    • giving the person their medicine
    • recording whether the person has taken or declined their medicine (see also recommendations on raising concerns)
  • Care workers should use a medicines administration record to record any medicines support that they give to a person. This should ideally be a printed record provided by the supplying pharmacist, dispensing doctor or social care provider (if they have the resources to produce them) (see also recommendations on supplying medicines administration records)
  • When social care providers have responsibilities for medicines support, they should have robust processes to ensure that medicines administration records are accurate and up to date. For example, changes should only be made and checked by people who are trained and assessed as competent to do so (see also the section on training and competency)
  • Ensure that medicines administration records include:
    • the person's name, date of birth and any other available person-specific identifiers, such as the person's NHS number
    • the name, formulation and strength of the medicine(s)
    • how often or the time the medicine should be taken
    • how the medicine is taken or used (route of administration)
    • the name of the person's GP practice
    • any stop or review date
    • any additional information, such as specific instructions for giving a medicine and any known drug allergies
  • When a family member or carer gives a medicine (for example, during a day out), agree with the person and/or their family member or carer how this will be recorded. Include this information in the provider's care plan

Managing concerns about medicines

  • Medicines use can be complex, particularly when people have several long-term conditions and are taking multiple medicines. Enabling people to raise any concerns about their medicines and managing medicines-related problems effectively when they happen are important to minimise harm and guide future care
  • When social care providers have responsibilities for medicines support, they must have robust processes for medicines-related safeguarding incidents, in line with Regulation 13 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. For guidance on ensuring safety and safeguarding people using home care services, see the NICE guideline on home care
  • When social care providers have responsibilities for medicines support, they should have robust processes for identifying, reporting, reviewing and learning from medicines-related problems. These processes should support a person-centred, 'fair blame' culture that actively encourages people and/or their family members or carers and care workers to report their concerns
  • Social care commissioners and providers should review their medicines-related problems over a period of time to identify and address any trends that may have led to incidents. They should share this learning with:
    • people working in the organisation
    • people receiving medicines support, their family members and carers
    • people working in related services, for example, GPs, supplying pharmacies and community health providers
  • Care workers should raise any concerns about a person's medicines with the social care provider. These concerns may include:
    • the person declining to take their medicine
    • medicines not being taken in accordance with the prescriber's instructions
    • possible adverse effects (including falls after changes to medicines; see the NICE guideline on falls in older people)
    • the person stockpiling their medicines
    • medication errors or near misses
    • possible misuse or diversion of medicines
    • the person's mental capacity to make decisions about their medicines
    • changes to the person's physical or mental health
  • Care workers and other social care practitioners should advise people and/or their family members or carers to seek advice from a health professional (for example, the prescriber or a pharmacist) if they have clinical questions about medicines
  • Health and social care practitioners should encourage and support people and/or their family members or carers to raise any concerns about their medicines. They should explain how to seek help or make a complaint, including who to complain to and the role of advocacy services (if needed), and record this information in the provider's care plan
  • Health and social care providers should ensure that people and/or their family members or carers, and care workers know how to report adverse effects of medicines, including using the Medicines and Healthcare products Regulatory Agency's yellow card scheme

Supporting people to take their medicines

  • Supporting people to take their medicines may involve helping people to take their medicines themselves (self-administration) or giving people their medicines (administration)
  • For guidance on self-management of medicines, see the recommendations on self-management plans in the NICE guideline on medicines optimisation
  • Social care providers should have robust processes for care workers who are supporting people to take their medicines, including:
    • the 6 rights (R's) of administration:
      • right person
      • right medicine
      • right route
      • right dose
      • right time
      • person's right to decline
    • what to do if the person is having a meal or sleeping
    • what to do if the person is going to be away for a short time, for example, visiting family
    • how to give specific formulations of medicines, for example, patches, creams, inhalers, eye drops and liquids
    • using the correct equipment, for example, oral syringes for small doses of liquid medicines
    • giving time-sensitive or 'when required' medicines
    • what to do if the person has declining or fluctuating mental capacity
  • Care workers should only provide the medicines support that has been agreed and documented in the provider's care plan
  • Prescribers, supplying pharmacists and dispensing doctors should provide clear written directions on the prescription and dispensing label on how each prescribed medicine should be taken or given, including:
    • for time-sensitive medicines:
      • what the medicine is for
      • what dose should be taken
      • what time the dose should be taken, as agreed with the person
    • for 'when required' medicines:
      • what the medicine is for
      • what dose should be taken (avoiding variable doses unless the person or their family member or carer can direct the care worker)
      • the minimum time between doses
      • the maximum number of doses to be given (for example, in a 24-hour period)
  • Social care providers should record any additional information to help manage time-sensitive and 'when required' medicines in the provider's care plan
  • Care workers should only give a medicine to a person if:
    • there is authorisation and clear instructions to give the medicine, for example, on the dispensing label of a prescribed medicine and
    • the 6 R's of administration have been met and
    • they have been trained and assessed as competent to give the medicine (see also the section on training and competency)
  • Before supporting a person to take a dose of their medicine, care workers should ask the person if they have already taken the dose and check the written records to ensure that the dose has not already been given
  • Care workers should ask the person if they are ready to take their medicine, before removing it from its packaging, unless this has been agreed and it is recorded in the provider's care plan
  • Care workers should give medicines directly from the container they are supplied in. They should not leave doses out for a person to take later unless this has been agreed with the person after a risk assessment and it is recorded in the provider's care plan
  • When a person declines to take a medicine, care workers should consider waiting a short while before offering it again. They should ask about other factors that may cause the person to decline their medicine, such as being in pain or discomfort (see also recommendations on raising concerns or seeking advice)
  • Supplying pharmacists and dispensing doctors must supply a patient information leaflet for each medicine supplied, in line with The Human Medicines Regulations 2012. This includes medicines supplied in monitored dosage systems
  • Social care providers should ensure that an up-to-date patient information leaflet for each prescribed medicine is kept in the person's home. This includes medicines supplied in monitored dosage systems
  • Social care providers should ensure that care workers are able to prioritise their visits for people who need support with time-sensitive medicines

Giving medicines to people without their knowledge (covert administration)

  • Covert administration of medicines is when medicines are given in a disguised form without the knowledge or consent of the person receiving them
  • Ensure that covert administration of medicines only takes place in accordance with the requirements of the Mental Capacity Act 2005 and good practice frameworks (Mental Capacity Act 2005: Code of Practice) to protect both the person and care workers
  • Care workers must not give, or make the decision to give, medicines by covert administration, unless there is clear authorisation and instructions to do this in the provider's care plan, in line with the Mental Capacity Act 2005
  • Ensure that the process for covert administration clearly defines who should be involved in, and responsible for, decision-making, including:
    • assessing a person's mental capacity to make a specific decision about their medicines
    • seeking advice from the prescriber about other options, for example, whether the medicine could be stopped
    • holding a best interests meeting to agree whether giving medicines covertly is in the person's best interests
    • recording any decisions and who was involved in decision-making
    • agreeing where records of the decision are kept and who has access
    • planning how medicines will be given covertly, for example, by seeking advice from a pharmacist
    • providing authorisation and clear instructions for care workers in the provider's care plan
    • ensuring care workers are trained and assessed as competent to give the medicine covertly (see also the section on training and competency)
    • when the decision to give medicines covertly will be reviewed

Ordering and supplying medicines

  • Responsibility for ordering medicines usually stays with the person and/or their family members or carers. However, if it has been agreed that a social care provider is responsible, effective medicines management systems need to be in place
  • Social care providers should agree with the person and/or their family members or carers who will be responsible for ordering medicines, and record this information in the provider's care plan. This should be the person, if they agree and are able to, with support from family members, carers or care workers (if needed)
  • When social care providers are responsible for ordering a person's medicines they must ensure that the correct amounts of the medicines are available when required, in line with Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
  • When social care providers are responsible for ordering a person's medicines they should not delegate this task to the supplying pharmacist (or another provider), unless this has been requested and agreed with the person and/or their family members or carers
  • When social care providers are responsible for ordering a person's medicines they should ensure that care workers:
    • have enough time allocated for checking which medicines are needed, ordering medicines and checking that the correct medicines have been supplied
    • are trained and assessed as competent to do so (see also the section on training and competency)
  • When ordering a person's medicines, care workers should:
    • record when medicines have been ordered, including the name, strength and quantity of the medicine
    • record when medicines have been supplied
    • check for any discrepancies between the medicines ordered and those supplied
  • Social care providers should ensure that care workers know what action to take if a discrepancy is noted between the medicines ordered and those supplied
  • Supplying pharmacists and dispensing doctors should supply medicines in their original packaging. They must make reasonable adjustments to the supplied packaging to help the person manage their medicines (for example, childproof tops), in line with the Equality Act 2010
  • Consider using a monitored dosage system only when an assessment by a health professional (for example, a pharmacist) has been carried out, in line with the Equality Act 2010, and a specific need has been identified to support medicines adherence. Take account of the person's needs and preferences, and involve the person and/or their family members or carers and the social care provider in decision-making
  • Supplying pharmacists and dispensing doctors should provide a description of the appearance of each individual medicine supplied in a monitored dosage system
  • Supplying pharmacists and dispensing doctors should consider supplying printed medicines administration records for a person receiving medicines support from a social care provider (see also recommendations on record keeping)
  • When social care providers have responsibilities for medicines support, they should have robust processes for managing over-the-counter medicines that are requested by a person, including:
    • seeking advice from a pharmacist or another health professional
    • ensuring that the person understands and accepts any risk associated with taking the medicine
    • what information needs to be recorded, for example, the name, strength and quantity of the medicine.

Transporting, storing and disposing of medicines

  • Responsibility for transporting, storing and disposing of medicines usually stays with the person and/or their family members or carers. However, if it has been agreed that a social care provider is responsible, effective medicines management systems need to be in place
  • Agree with the person and/or their family members or carers who will be responsible for transporting medicines to or from the person's home. If a social care provider is involved, carry out a risk assessment of transport arrangements
  • Agree with the person how their medicines should be stored and disposed of. Encourage the person to take responsibility for this, if they agree and are able to, with support from family members, carers or care workers (if needed). Record this information in the provider's care plan
  • When a person is assessed to be at risk because of unsecured access to their medicines, social care providers should agree with the person and/or their family members or carers whether secure home storage is needed, for example, in a lockable cupboard
  • When social care providers are responsible for storing a person's medicines, they should have robust processes to ensure there is safe access to medicines, particularly for controlled drugs (for more information see NICE's guideline on controlled drugs). These should include:
    • identifying who should have authorised access to the medicines
    • seeking advice from a health professional about how to store medicines safely, if needed
    • ensuring there is a safe storage place or cupboard for storing medicines, including those supplied in monitored dosage systems
    • assessing the need for secure storage, for example, in a lockable cupboard
    • identifying the need for fridge storage
    • reviewing storage needs, for example, if the person has declining or fluctuating mental capacity
  • When social care providers are responsible for disposing of any unwanted, damaged, out-of-date or part-used medicines, they must have robust processes, in line with The Controlled Waste (England and Wales) Regulations 2012. These should include:
    • obtaining agreement from the person (or their family member or carer)
    • how the medicines will be disposed of, usually by returning them to a pharmacy for disposal
    • any special considerations, for example, for disposal of controlled drugs, needles and syringes
    • what information needs to be recorded, for example, the name and quantity of medicine, the name of the person returning the medicine, the date returned and the name of the pharmacy

Training and competency

  • Appropriate training, support and competency assessment for managing medicines is essential to ensure the safety, quality and consistency of care
  • When social care providers are responsible for medicines support, they should have robust processes for medicines-related training and competency assessment for care workers, to ensure that they:
    • receive appropriate training and support
    • have the necessary knowledge and skills
    • are assessed as competent to give the medicines support being asked of them, including assessment through direct observation
    • have an annual review of their knowledge, skills and competencies
  • Follow the advice on recruiting, training and supporting home care workers in the NICE guideline on home care

Terms used in this guideline

Advance care planning

  • A voluntary process of discussion about what care a person would or would not want in the future, if they were unable to make decisions because of illness or a lack of mental capacity to consent. The person may also choose to involve their family members or friends in discussions

Carer

  • The term 'carer' is used to define an informal, unpaid carer only (see also 'care worker')

Care worker

  • A person who is employed to provide care and support to people in their own home. This includes home care workers, personal assistants (who are directly employed by people who use services) and other support workers

Fair blame culture

  • In health and social care, this enables open and honest reporting of mistakes that are treated as an opportunity to learn to improve care

Health and social care practitioners

  • The wider health and social care team of health professionals and social care practitioners. Health professionals include, but are not limited to, GPs, pharmacists, hospital consultants, community nurses, specialist nurses and mental health professionals. Social care practitioners include, but are not limited to,care workers, case managers, care coordinators and social workers. When specific recommendations are made for a particular group, this is specified in the recommendation

Medicine

  • All prescription and non-prescription (over-the-counter) healthcare treatments, such as oral medicines, topical medicines, inhaled products, injections, wound care products, appliances and vaccines

Medicines-related problems

  • Medicines-related problem include:
    • potentially avoidable medicines-related hospital admissions
    • prescribing errors
    • dispensing errors
    • administration errors (for example, missed or delayed doses, inappropriate or incorrect administration)
    • monitoring errors (for example, inadequate review or follow-up, incomplete or inaccurate documentation)
    • adverse events, incident reporting and significant events
    • near misses (a prevented medicines-related patient safety incident which could have led to patient harm)
    • deliberate withholding of medicines or deliberate attempt to harm
    • restraint or covert administration that has been used inappropriately
    • misuse, such as missing or diverted medicines
    • other unintended or unexpected incidents that were specifically related to medicines use, which could have, or did, lead to harm (including death)

Medicines support

  • Any support that enables a person to manage their medicines. This varies for different people depending on their specific needs

Mental capacity

  • The ability of a person to make a decision about their own care, including:
    • decisions that affect daily life (for example, when to get up, what to wear or whether to go to the doctor when feeling ill, and more serious or significant decisions)
    • decisions that may have legal consequences for them or others (for example, agreeing to have medical treatment, buying goods or making a will)
  • The Mental Capacity Act 2005 defines a lack of mental capacity as when 'a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain'
  • Health professionals should follow the Department of Health's advice on consent. If a person does not have capacity to make decisions, health and social care practitioners should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards

Monitored dosage system

  • A system for packing medicines, for example, by putting medicines for each time of day in separate blisters or compartments in a box

Original packaging

  • The packaging in which the medicine is supplied by the supplying pharmacy. This could be a manufacturers packaging or pharmacy supplied packaging after larger amounts of medicines have been decanted for individual patient use

Parenteral nutrition

  • Providing nutrients intravenously

Provider's care plan

  • A written plan that sets out the care and support that providers and the person have agreed will be put in place, following a local authority assessment. It includes details of both personal care and practical support

Social care provider

  • A provider organisation, registered with the Care Quality Commission to provide community adult care services, which directly employs care workers to provide personal care and support in a person's home

Time-sensitive medicine

  • A medicine that needs to be given or taken at a specific time, where a delay in receiving the dose or omission of the dose may lead to serious patient harm, for example, insulin injections for diabetes or specific medicines for Parkinson's disease
  • For other health and social care terms see the Think Local, Act Personal Care and Support Jargon Buster

References

full guideline available from...
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/NG67

National Institute for Health and Care Excellence. Managing medicines for adults receiving social care in the community. March 2017.


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