Safe Handling of Medication

Derbyshire House believes that the safe handling of medication plays a major part in the health and well-being of the people who live with us. We have formed good relationships with the G.P.’s at the local surgery and the pharmacist who supply our medication, which supports good practice when administering, dispensing and managing medication. We follow the NICE guidelines – Managing Medicines in Care Homes and help to keep service users safe. The purpose of this document is to give guidelines for all staff who manage, dispense, administer or deal with any medication issues, to be able to do so safely. Our procedures are as follows: –

  • Our dispensing pharmacy who provides our medication is Boots of 11-13 Market Place, Loughborough, Leicestershire, LE11 3EQ. Tel: 01509 262168, Fax: 01509 237912, Email: . They provide six monthly visits to our home and audit our medication and the procedures we have in place and provide us with feedback to ensure we continually maintain and improve our standards. They are also available for medication advice as and when required. An in-house audit is also completed by the Administrator periodically, to ensure compliance and queries are managed appropriately. Any queries identified are dealt with as they occur.
  • Prescriptions are ordered four-weekly online by day eight of each four weekly cycle, through “Systm 1” to the G. P’s surgery for approval by the G.P. Staff permitted to use Systm 1 have completed GDPR training with the manager, who is the appointed person by the CCG and access is password protected. Every time you access the system a record is made on the “Systm 1 log in sheet” stating date, time, who logged on, reason for logging on and signed. A copy of each prescription request is stored on the designated “Systm 1” laptop should any queries arise. Medications prescribed are then received by Boots in Loughborough, they will email or phone a missing items sheet to us, if any regular medication appears to not have been ordered to ensure any medication required is not missing. Boots deliver medication to the home. This enables the quantities of drugs held on site to be kept to a minimum.
  • The majority of medication prescriptions are able to be sent electronically to Boots. If a medication is not able to be sent electronically and not urgent the surgery will post it to Boots, or Boots will arrange collection from the surgery. In general, the cut off times for prescriptions are – prescriptions received by 5.00pm will be delivered the following day between the hours of 9.00am and 5.00pm. If a medication is very urgent Boots will deliver the same day, if possible, if they cannot deliver that day Evans Pharmacy in the village are happy to provide it at short notice. If an urgent prescription is required out of hours i.e., antibiotics, we are able to call 111 who will be able to direct us to the nearest pharmacy that is open.
  • On admission to the home, residents and/or family members are asked to complete a family doctor services registration form or notification of change of address form (if they are already a patient at the practice) and a consent form for online record access, to complete the registration with the surgery. The home also completes a service user update form for Boots via secure email or phone to ensure all relevant parties have the necessary medication details including any allergies for all existing and new residents.
  • All deliveries of medication are secured immediately. When booking in medication we will check :-
    • All medication ordered is received and any anomalies are followed up as soon as possible
    • All medication is labelled with a resident’s name, if it is not, it will be returned and reordered
    • Medication names, generic and brand name, it is important that the label on the box is checked against the medication inside the box and on the MAR chart to ensure the correct medication is there before administering it. If in any doubt the GP or pharmacy should be called to clarify.
    • Expiry dates and note any that are short dates
    • If a prescription states “as directed” it must be referred back to the prescriber for clarification
    • Quantities received and recorded on the MAR chart including any quantities brought forward and ensure this is signed
    • To ensure old stock brought forward is rotated
    • Residents’ medication is kept in individual boxes with their name, picture, hallway and room number on and stored in a locked cabinet attached to the wall
    • If a resident is admitted from a hospital or another care setting then all medication will be checked against the discharge notes and any irregularities will be checked with them
  • Individual I.D sheets are placed in the front of each residents MAR sheets to minimise the risk of mistakes being made. These include a current photo (dated and reviewed six monthly), name (and name they like to be called), hallway and room number, D.O.B, GP’s name, pharmacy, next of kin and any allergies. There is a section detailing all PRN medication prescribed and also personal/cultural preferences regarding medication i.e., religious needs – fasting – cannot take medication before a certain time, dietary beliefs – vegan – gelatin in capsules is not suitable, general beliefs – no medication that is tested on animals, (if these preferences were identified it would be referred to the GP and/or Clinical Pharmacist) and any other helpful information required.
  • The choice of handling and dispensing medication is sought on admission as to whether people manage their own medication or alternatively want to give this responsibility to the home. A risk assessment is completed for residents who wish to administer their medication themselves and reviewed six monthly, or more frequently if an issue is identified. In some instances, a referral may need to be made to the GP/Clinical Pharmacist to complete a best interest checklist in accordance with section 4 of the Mental Capacity Act 2005, if there are any doubts regarding capacity.
  • Self-medicating residents are asked to sign the MAR sheet every 4 weeks to confirm the medication they have received.
  • All medication stored at Derbyshire House is signed for as received on the individuals MAR sheet which is provided by our pharmacist. We are also provided with blank forms for medication received from other pharmacies. These are kept locked in the home’s medication rooms.
  • The medication rooms temperatures are monitored and recorded daily (the temperature should be between 15 and 25 degrees Celsius). If the temperature is below 15 or above 25 degrees then this needs to be reported to the senior on duty. The senior should then make all the relevant checks to find out why the temperature is not within the correct range. This may be because the air conditioning unit is not working correctly, in which case it should be reported to management. Advice should also be sought from the pharmacist to ensure that the medication being stored is still suitable for use.
  • Any handwritten additions to MAR charts are countersigned in the medication profile box. The information regarding the medication on the MAR sheet should be the same as the information recorded on the medication label printed by the pharmacy.
  • Some medicines need to be given once a week e.g., for osteoporosis or every few days e.g., patches for pain relief. Care should be taken when giving these medicines to ensure they are given as per the prescribers and manufacturer’s instructions. It is important that it is clear on the MAR chart when these medicines are to be given. If some medication is given at the wrong time with other medication, it may have an adverse effect on the medication they are taking. It is recommended that all days except the day it is given are crossed through on the MAR sheet.
  • Medication required to be refrigerated should be stored in a fridge in a number locked medication room. The fridge temperature should be monitored with a max/min thermometer daily (the temperature should be between 2 and 8 degrees Celsius). If the temperature is below 2 degrees or above 8 degrees it should be reported to the senior on duty who should make all relevant checks and adjustments/arrangements to rectify the problem. This may be that the thermometer has been moved within the fridge or damaged, or the vent is blocked at the back of the fridge. The outside surroundings of the fridges should be kept clear and vents unobstructed as this may cause the fridges to overheat. The fridges should be cleaned on a regular basis and recorded, If the problem cannot be dealt with this should be reported to management. Advice should also be sought from the pharmacist to ensure that the medication being stored in there is still suitable for use.
  • Medication is dispensed in accordance with individual MAR sheets and in line with NICE guidelines – the right resident receives the right medicine, via the right route, the right dose at the right time. The date the medication is opened should be written on the box/bottle/container. Medication should be dispensed in the order they appear on the MAR sheet and one at a time ensuring each medication strip is placed back into its box before dispensing the next. Some residents will be prescribed multiple strengths of the same medication and care should be taken to ensure that the correct one is being given at the correct times. To reduce the risk of an error the home colour codes these medicines wherever possible. If the medication has a variable dose the number of tablets that are given will be recorded on the MAR chart. Staff should use single use disposable medicine pots. Any medications e.g., creams that are administered separately should be cross referenced on the MAR chart.
  • Medicines prescribed for one person should not be used for another, unless an out of hour’s emergency professional or a G.P authorises this.
  • The BNF or MIMS books and/or the Boots Patient Information Leaflets file (in Primrose medication room) can be referred to for possible side effects or adverse reactions. If a reaction has occurred, it should be reported this to the Manager or her deputy.
  • Advice is sought from the Manager or her deputies, before dispensing analgesics for pain relief and/or other reasons (tablets of paracetamol) that have not been prescribed.
  • No alteration, or cessation of the administration of any drugs should occur without consultation and approval of a G.P or other relevant professional. The G.P/relevant health professional will be required to sign the MAR sheet confirming this.
  • Should a person refuse to take their medication this should be clearly recorded and the Manager and GP informed. Their advice will then be acted upon.
  • Once creams are opened, they should be dated and any creams left over after twelve weeks should be returned to the pharmacy and replaced with new ones.
  • The medication rooms are secured by a number lock that only designated staff know and keys to the medication cabinets are stored in the locked medication rooms.
  • All incoming medication without a clear label stating name, medication, strength, expiry date, dose, frequency of use, start and end dates, will be referred back to the pharmacist.
  • Individuals’ medicines are reviewed on admittance to the home and annually or on condition change thereafter. This is done by completing a structured medication review proforma and sending it to from a secure email account. This should be followed up by a call to: 01158834230 to the Clinical Pharmacist for Partners Health and Rushcliffe PCN to arrange with the home, resident and family a review to see if any changes need to be made. As we have G.P rounds weekly, medication is monitored on a more regular basis.
  • When it is necessary for residents to take medication out of the building, all medication should have the dispensing label attached, be in a suitable container and a holiday or day leave medication tracker completed stating: name, date of birth, room number, date of leave, name of medication being given, strength, form, dose, quantity, date signed out by whom and who given to. When the medication is returned the quantity of medication will be checked and signed to say it is correct.
  • Unused medication is listed in the medication returns book and signed by a senior staff member and a counter signature and returned for secure disposal to Boots in Loughborough where their signature is also obtained. The original copy is taken by Boots and a copy is retained by the home. After a death, medication including anticipatory is stored at the home for seven days before being returned to the pharmacy, in case there is a need for a coroner’s inquest. If any controlled medication is returned this should be recorded on a separate sheet, put into a sealed bag and given to the pharmacist. Returns records are audited yearly by the CCG to ensure there are no common themes on returns and to ascertain if there are any financial savings that could be made by the NHS in the future.

PRN (when required) Medication (i.e., Paracetamol)

Medicines with a PRN (pro re nata) or ‘when required’ dose can treat many different conditions. Examples include nausea, vomiting, pain, indigestion, anxiety or insomnia. People with long term conditions may also use PRN medication for example, inhaled reliever medicines for people with asthma. If a resident is prescribed PRN medication by the GP a PRN ‘when required’ the medication protocol, PRN medication record and the residents care plan is updated and completed. These forms should contain enough information to support staff to administer when required medicines as intended by the prescriber and are given in a culturally appropriate way. This should include:

  • The reason for giving the ‘when required’ medicine e.g., for back pain etc
  • How much to give (dose, how often and maximum dose in 24 hours)
  • What the medicine is expected to do
  • The minimum time interval between doses
  • When to use another prn medication if the first does not work (e.g., this may be used in anxiety or epileptic residents) there may also be more than one option available and there should be a clear plan of what order they should be taken in i.e., multiple painkillers you might try paracetamol first then codeine if the first does not work
  • When to check with the prescriber or alert them
  • Signs and symptoms the resident may display if unable to communicate their need for the medicine
  • A review date agreed with the prescriber

Administration and Ordering

When administering and ordering prn medication it is important that the following procedure is followed: –

  • It is good practice to ask the resident whether they would like their prn medication when carrying out the ward round or ask them if they would prefer to tell us when they require it ensuring we stay within the boundaries of the protocol
  • If the medication is refused code N (offered but not required) should be written on the MAR chart
  • Where a medication is used for seizures or angina attacks these should only be recorded when they are used i.e., no code will be written routinely
  • The time the medication is given should be recorded to ensure there is the correct interval between doses
  • The time given or applied, quantity given, the reason given and the response to the medication will be recorded If it is a variable dose the amount given will also be recorded i.e., 1 or 2
  • If any prn medication is given regularly then a referral to the GP will be considered as the resident’s treatment may need altering
  • All prn medication will be stored in its original packaging wherever possible, and checked they are not out of date
  • PRN medication will only be ordered if needed and any unused medication will be counted and carried forward to the following month
  • Any prn creams will have a date on when they are opened as some creams have a limited life span
  • If any prn medication is stopped/discontinued by the GP it will be crossed off the MAR chart and countersigned by a second member of staff and any unused medication will be returned to the pharmacist for disposal
  • A review date for each prn medication will be agreed with the prescriber

Controlled Drugs

Controlled drugs (CDs) i.e., morphine, are subject to stricter regulations than other medicines because of the potential for them to be misused and/or abused. We adhere to the legal requirements for the storage, administration, records and disposal of CDs as set out in the Misuse of Drugs Act 1973 (Safe Custody) Regulations. Our procedure for CDs is as follows: –

  • They are only kept for individuals that are prescribed by a GP or other healthcare professional
  • CD prescriptions are sent remotely to Boots our designated pharmacy and are delivered direct to the home by them to avoid any misplaced/stolen prescriptions being able to be used
  • They are stored in a metal CD cabinet that is attached to a solid brick wall and is attached with rawl/rag bolts and has a double locking mechanism
  • The keys for the CD cabinet are stored securely in the locked medication room
  • Only CDs are stored in the cupboard
  • All CDs that are received, are signed for entered onto the individuals MAR chart and recorded in a bound CD register for each individual on the day it is received, it is in chronological order, entries are made in ink, detailing the residents name, where received from, quantity received, the drug name, strength and form is entered at the top of the page and are signed for and witnessed by trained staff members, there is also an index at the front of the book indicating where each resident’s details can be found
  • All CD’s that are dispensed and administered are recorded on the individual’s MAR chart and in the CD, book detailing the date, name of the individual, quantity given (liquid CDs will be measured using an oral syringe, balance in stock (this is checked before and after administration to highlight any discrepancies, please note liquid medication is visual) and signed for by two trained members of staff
  • No crossing out or overwriting and correction fluid will not be used, if an error is made: –
    • Next to the incorrect entry and at the bottom of the page put an asterisk (*)
    • Next to the * write what has happened, what the correct entry should be, sign and date and ensure it is countersigned
    • Continue the entry on the next line

If the balance is not correct: –

    • The CD register and cupboard will be checked with a witness
    • The CD register will be checked against the MAR chart, to see if an entry has been missed
    • The returns record will be checked to see if it has been returned or destroyed

If it is a missed entry then under the last entry we will write: –

    • Date error was discovered
    • What happened e.g., dose administered but not recorded at the time
    • Amend the balance to account for the error
    • Amended entry will be checked and countersigned by a witness

If it is a calculation error, under the last entry the following will be recorded: –

    • The date
    • The error deducted/added indicated with an asterisk
    • The correct balance
    • The signatures of the trained staff and countersignature
  • The CD register will be kept in a secure place when not in use, completed registers will be kept for a minimum of two years after the date of the last entry and archived in a safe place
  • Some CDs are only administered by a District Nurse, through a syringe driver or by injection, in these cases the nurse will record in the CD register of what quantities of medication have been used and will be countersigned by a staff member (if the nurse refuses to complete the CD register the home will record in the register (including the refusal) and also on the MAR chart to ensure there is an audit trail
  • Some CD medications have an expiry date i.e., Oramorph oral solution (Morphine Sulfate) once opened it can be used for three months after which it must be returned to the pharmacy and a new prescription if needed requested from the GP
  • Once a CD is no longer required it is returned to the pharmacy
  • On occasion we receive notifications from the CCG and Nottinghamshire County Council informing us of changes in medication classification at which point a medication could become a controlled drug or best practice to do so. At this point we would ensure the medication follows the controlled drugs protocol
  • If a resident wishes to self-administer their controlled drug a risk assessment will be completed which will include the residents understanding of why the medication has been prescribed, how much and how often to take it and what may happen if they do not take enough or too much, when this medication is received it will be booked in and out of the controlled drugs book before giving to the resident and the resident will be provided with a locked cupboard or drawer in their room

Oral Anticoagulants (i.e., Warfarin): These types of medication are prescribed to thin the blood in those who may be susceptible to blood clots and it is therefore vital that the individual receives the right dose. We treat these as a controlled drug and follow the procedure for this. Regular blood tests and monitoring are required and the following procedure should be followed: – the results of each blood test should be communicated by the local surgery, information required by them is the name of the person making the call, the name of the individual they are talking about, the INR level, the daily dose, the next test date and has it been booked, this information should be recorded in the individuals care plan and on a separate sheet in the MAR sheet file. The date should also be written in the diary.

Anticipatory Medication: This is treated in the same way as controlled drugs, where two signatures are required for all movements. A record of all the medicines administered by the District Nursing team will be recorded in the controlled drugs book. A nurse will be asked to be one of the signatories but if he/she is unable to do so this will be the responsibility of the senior or duty senior to complete. It is also recommended that the duty senior is in the room with the nurse when the medication is administered. All nurse’s documentation relating to this should be made available to the home. This medication is routinely checked every four weeks in line with the medication changeover.

Procedure in Case of a Drug Error: We make every effort to avoid any drug errors by providing training and supervision, and advice and guidance to all our staff that have the authority to administer and dispense medication. However, we are all human and we accept that humans make unintentional mistakes.

In the event of an error with medication, which could be administering medication to the wrong resident, giving the wrong dosage, not following the correct procedure, giving via the incorrect route, or not giving the medication at all, we follow this procedure to ensure the best possible outcomes.

We will inform the registered manager and a G.P, and have all the relevant information to hand, i.e., list of prescribed medication and the drug, which has been wrongly administered and how and why this happened. The G.P will either:

  • Reassure that the drug will do no harm
  • Inform of the possible side effects to be observed
  • Arrange emergency admission to the hospital

We will also inform the dispensing pharmacist and the person’s relatives. We will complete full and accurate records in relevant books and depending on the severity of the incident; inform the CQC (Care Quality Commission) and the CCG quality team ( if it is serious i.e., the resident has been admitted to hospital and if the incident could have caused harm we will inform the relevant safeguarding team (Nottinghamshire – MASH (Multi-Agency Safeguarding Hub Tel – 0300 5008090 email of this error and what we did when this occurred, if necessary. If the incident involves controlled drugs, we will report this to region north midlands and the local police if controlled drugs cannot be accounted for.

Procedure for Reporting Other Medication Related Incidents: If other medication related incidents occur, i.e., loss or damage of prescription, staff should:

  • Firstly, inform the Manager, ensuring they have all relevant information to hand, i.e., details of the incident that has occurred and how and why this has happened.
  • The Manager will inform the GP and the dispensing pharmacist.
  • The staff member will then complete full and accurate records in relevant incident and any other record books.
  • The Manager will then inform the CQC of the incident.
  • We will review this incident to see if we can change our policy or procedure or provide any necessary training in order to reduce the risk of it happening again.

Procedure for receiving and returning medication whilst dealing with COVID-19 and other infectious diseases

  • The pharmacy should be informed/kept up to date with the home’s situation
  • Medication should continue to be ordered on a 28-day cycle
  • Delivery/collection drivers will drop off contactless
  • Medication delivery trays/boxed and crates that are used to transit medicines to and from the home, will have to remain in the home until the infection is over
  • Medication should be signed for whilst wearing suitable PPE

Difficulty in Obtaining Medication: Derbyshire House understands that at times situations can occur where there may be difficulties in obtaining medication; i.e., the medication is no longer made. On these occasions we would liaise with both the surgery and the pharmacy for an alternative to be prescribed. If a national issue occurs i.e., a ‘no deal’ Brexit we have/would consulted/consult with Boots and our business continuity plan has been/would be updated in line with recommendations made by the Council and Clinical Commissioning Group (CCG).

Training and Competency

Medication dispensing and administration will only be carried out by staff that are appropriately trained and have had their competency assessed yearly to ensure medicines are given in a safe and legal manner. If a staff member is involved in a medication error/near miss, competency assessments may be undertaken more frequently to support any learning and development needs. All staff during their induction will be informed of their responsibilities regarding medication i.e., how to respond if a resident asks for a medication and who they should inform.