Managing medication

BETAThis is a new web page — your feedback will help us to improve it.

Care Homes have an overriding duty of care to the people they look after which includes ensuring they always have enough of the right medication at the right time to meet all of their resident’s needs.

This means that you must be able to evidence that you have been pro-active in addressing any concerns or issues, for example keeping copies of e-mails to pharmacies if the wrong medication has been received, or if medication has not been received as agreed. It is not acceptable to give "we thought the pharmacy was closed" as a reason for not having medication. There is always an alternative, for example as using out of hours GPs, pharmacies, 111 or another  process.

Communication is key to good and safe medication management

The care home manager, community pharmacist and GP surgery should have in place relationships which ensure they understand each other’s systems, processes and needs. Connecting individuals with specific responsibilities will help this.

The pharmacy and care home should meet regularly (at least annually or as required) to ensure they understand each other’s responsibilities and constraints and address any concerns. 

The pharmacy and GP practice should agree a system for raising queries with the home. For example, an agreed contact or agreed time to call.

Medication errors and incidents should be recorded and reviewed by all parties on a continual basis and measures should be put in place to minimise further patient harm. Reports should be made to safeguarding if harm has or could have occurred.

The care home should be aware of emergency and out of hours support services, such as:

Issues around prescribing

Directions

GPs should ensure all medicines have clear directions for use. Medicines must not be given to the home with ‘as directed’ instructions. This is in contravention of NICE guidelinesExternal link.

  • if the care home is unclear or uncertain about any aspect of medication they should contact the pharmacist to discuss what is best for the resident and to encourage a personalised administration process
  • where possible the prescriber and/or pharmacist should specify the time of day the medicine should be taken (morning, lunchtime, teatime, bedtime)
  • all labels for eye or ear preparations should give specific directions about whether it is to be applied to right, left or both eyes/ ears
  • all medicines must have a specific dose e.g.’ one puff twice a day’ not ‘use twice daily’

All topical preparations should have directions that include:

  • how they should be used e.g. as soap substitute, liberally, sparingly etc.
  • where they should be used e.g. legs
  • frequency of use, e.g. in the morning after washing, as often as required to alleviate itchiness, three times a day etc.
  • the duration of treatment, especially for creams containing steroids and antimicrobial constituents

Repeat medicines

  • Ensure that repeat medication is synchronised so that medicines are not missed or ordered mid-month.
  • On admission to a care home a patient may need a different quantity of medicines to take them up to the beginning of the next full cycle. This will help the care home manage any waste and should be discussed with the pharmacy
  • GP practices should remove unwanted medicines from the repeat prescriptions. Unwanted items should be communicated by the care home to the GP to remove from the prescription or via the pharmacy
  • Prescribe the quantity of medicines needed only for the repeat cycle
  • For bulky items such as lactulose, prescribe only what is needed for the repeat cycle and not necessarily original packs
  • If possible identify a key contact from the GP practice to liaise with and act as a point of contact for the care home. This is particularly helpful when dealing with repeat prescriptions.

When required (PRN) medicines

When medicines are prescribed for use ‘when required’ there must be systems in place to ensure that stock is kept at safe levels and to prevent medication being given that has expired.

For the prescribing of ‘when required’ medicines include all relevant information to allow staff to administer the medicine to assist the carer.

Where there is a choice of dosages for a patient’s medication, for example, 1-2 to be taken…further guidance is required from the GP or pharmacist to clarify the situations in which one dose should be given and those in which two doses should be given, the time between doses and the signs that indicate that a further dose may be required.

It is recommended that all homes develop clear individualised ‘prn protocols’ for each ‘when required’ medicine so that staff are clear of the reasons for each prescription for each resident and the symptoms to look out for.

For example,

  • one to be taken when required to aid sleep. What does this look like e.g. if the person is still awake after 2 hours?
  • if instructions say take one or two when should you give one and when should you give two?
  • if the individual is non-verbal how do you know when they require the medication? For example, if the medication is prescribed take for agitation what does that look like? How does the individual express pain? Do they rock or hold their sides?
  • what is the maximum dose in 24 hours?  NICE and pharmacy guidelines indicates that a maximum dose in 24 hours or per episode must be stated on the label.
  • if there is any doubt about the dose schedule for a ‘when required’ medicine this should be clarified with the GP or pharmacist. This is to enable a personalised medication plan to be developed

It is difficult to predict how much ‘when required’ medication a patient will need in the 28 day cycle. This can result in significant amounts of medication being wasted only for a replacement supply to be reordered the following month. Procedures must therefore be set up and adhered to prevent wastage of when required medicines.

It is acceptable for homes to retain ‘when required’ medicines and carry these forward onto the next MAR sheet each month, dependent upon expiry dates.

It is best for PRN medicines to be dispensed in original containers. Medicines that have been dispensed for residents in their original packaging may be retained until the expiry date printed on the pack or strip, providing the PRN medicines is being given for the original condition for which the prescription occurred.

Further advice about expiry dates of ‘when required’ medicines, creams and liquids can be found at the British National Formulary External link.

If PRN medicines are dispensed into a monitored dosage system (tray/ blister) then a two month shelf life is usually given, after which the medicines will need to be replaced. This can be discussed with the community pharmacy as it may be more appropriate to have these items dispensed in their original packaging.

If PRN medication is regularly being returned for disposal, ask the GP to prescribe smaller quantities and ask the community pharmacy to supply them in original containers.

Prescription management

Regular prescriptions

Regular medicines should be ordered together, once monthly to reduce the risk of errors.

Any unused doses (e.g. where odd doses have been refused or not taken or where medicines have been discontinued or changed) should be disposed of appropriately. Residential homes should have these medicines collected by the dispensing pharmacy whilst nursing homes will have a contract with a waste disposal company who will collect their medicines and other clinical waste.

If medication is left at the end of a cycle but the MAR sheet has been signed showing all doses have been given this should be investigated by the unit manager to find out why. 

It is acceptable to ‘carry over’ regular medicines where there is a suitable supply left and the items are within their expiry date, or where failing to carry the supply over will leave a patient without medicines.

When carrying forward regular medicines, always check the expiry date on the packaging. Monitored dosage systems, however, usually only have a two month shelf-life because of medication stability.

The NICE guidelines 2014 for ‘Managing medicines in care homes’ concluded that ‘provided the medicine is still currently prescribed, is within its expiry date, and is still in its original container, and the manufacturer’s literature does not specify a short shelf life when the product is opened, there is no requirement for the medicine to be disposed of early and it should be carried forward to the next 28-day supply cycle’. This is particularly important when considering the expiry dates of creams/ ointments once opened.

If information on a recommended shortened expiry date cannot be found in the Patient Information Leaflet, an expiry date of 12 months, once opened, should be followed for topical preparations. Alternately the British National Formulary can be accessed here External link.

Acute and interim prescriptions

  • GPs should prescribe the amount likely to be needed.
  • GPs and pharmacists must record clear instructions on how the medicine should be used, how long the resident is expected to need the medicine, what the medicine  has been prescribed for (use of ‘as directed’ is not acceptable under Royal Pharmaceutical Society Guidelines External link ) and a date of review.
  • When an ‘acute’ prescription is started it should be clear to the care home that it is for a specified period of time.
  • Ensure any records made on handheld portals or remotely are updated securely onto the patient’s clinical record e.g. smart phone or tablet with electronic care or electronic MAR systems

Ordering of medicines

Check stock and order only what is needed to cover the next 28 day cycle.

A photocopy should be taken of what has been ordered before sending the request to the GP surgery so any queries can be looked into.

Prescriptions will be generated by the surgery and then sent back to the home to be checked for any discrepancies against the record of what has been ordered. They should then be sent to the community pharmacist to be dispensed.

Care home staff should communicate with the community pharmacist if items need to be removed, any doses changed or new medications added.

If an item is no longer required by the service user, a further supply must not be ordered. It should be removed from the prescription list after consultation with the GP as appropriate, and removed from the MAR sheet by contacting the pharmacy.

In some cases an EPS (Electronic Prescription Service) may be used. This enables prescribers to send prescriptions electronically to a dispenser (such as a pharmacy) of the patient’s choice. To send prescriptions via EPS there should be an agreement between care home, pharmacy and GP practice about how the scripts will be checked before they are dispensed.

Where EPS is used, the care home should be provided with a ‘token’ which should be checked against what has been ordered, prior to sending to the community pharmacist. In reality this will be a paper record of what was ordered when it is delivered by the pharmacy.

Ordering may also be done by the care home via an online ordering system. This method will reduce the potential for errors and discrepancies with orders to the GP practice. All care home staff involved in ordering online must be trained on how to use the system.

Method for carrying forward medication from one cycle to the next

The medication name, strength, formulation and dose of the medication must be transposed onto the new MAR sheet.

Discuss this with the community pharmacy. If they dispensed the original item they may be able to leave it printed on the new month’s MAR sheet without dispensing a further supply, with a note stating ‘not dispensed this cycle’ or similar.

The balance of tablets (or an estimation of liquids) carried over to the new MAR sheet must be written onto the chart to enable an audit trail to exist.

The entry (any handwritten entry) should be signed and dated and a witness should countersign the entry.

Risk Assessment/ Self-administration

The preferred option is always for an individual to manage their own medicines and a medication assessment should be completed by the care provider with the aim of maximising an individual’s independence in managing their medication.

The assessor should determine who else may be involved. This should be done individually for each person and should involve the person themselves, their family or carer, or care staff with the training and skills for assessment.

Care providers undertaking assessments should liaise with the pharmacist or GP to ensure that where possible, medicines are prescribed and dispensed appropriately in order for the person to retain their independence.

Self-administration of medicines is not an ‘all or nothing’ situation and a well done assessment will identify ways of improving independence possibly changing the format

Homely Remedies

Homely or household remedies are also known as non-prescription medicines, which refers to medicines available over the counter in community pharmacies. These may be used in a care home for the short-term management of minor, self-limiting conditions. For example, cough, headache, indigestion etc.

There is a recognised duty of care by staff within a care home to be able to make an appropriate response to symptoms of a minor nature.

The GP should be informed of any non-prescribed medicines being taken by residents. This will ensure a complete profile of medication is included in their patient medication records to identify any interaction with prescribed medication or diet and monitor for possible adverse effects.

Most homely remedy policies held by care homes contain a list of the following items for care home staff to make an appropriate response to symptoms of a minor nature. These items should not be requested on prescription from GPs for short-term use of minor ailments:

  • Paracetamol for occasional pain
  • Indigestion remedies (e.g. magnesium trisilicate mixture)
  • Constipation remedies (e.g. senna, lactulose)
  • Remedies for diarrhoea (e.g. rehydration sachets)
  • Cough remedies (e.g. simple linctus)

The non-prescribed medicines should be agreed locally with the GP and pharmacist and restricted to a limited list to reduce the risk of adverse reaction or interaction with prescribed medication.

A homely remedy policy held by the care provider should include:

  • the limited range of remedies that are kept
  • the indications for offering the medicines and the limit on duration of treatment
  • the dose to be given and how often it can be repeated before referring to the GP
  • how to establish with the GP that the remedy will not interact with other prescribed medicines

The GP should be informed if homely remedies are used for more than 48 hours and symptoms still persist. The MAR sheet should confirm this.

The administration of homely remedies must be fully recorded on the MAR sheet.

The care provider may request directions of use via a fax/ secure email from the GP to be transcribed by the carer onto the MAR sheet with a second accuracy check and signature.

Covert administration

A clear distinction must be made between those people who have capacity to refuse medication and whose refusal should be respected, and those who lack this capacity.

All principles about covert medication administration should be guided by the core principles of the Mental Capacity Act (2005).

See CQC guidance on covert medication hereExternal link.

Medication record requirements in care homes

The manager will ensure that a written record is kept of all medication entering a care home that is being administered to the resident or sent for disposal.

Information must be kept and regularly updated and checked.

Amendments must be made immediately as they occur.

A regular audit of records produced by the care homes is recommended.

The responsible manager must have a written protocol in place which staff are aware of. All staff allowed to administer medicines should be listed by name at the beginning of the MAR sheet folder with a sample signature that they use on the MAR sheet.

A complete record of all medication administered/ not administered must be kept for each service user and for each medicine.

When changes to medication are needed, it is the responsibility of the care provider to keep the MAR sheet up to date.

If the GP issues a new written prescription (which can be issued at any time in the monthly cycle), there should be a new MAR sheet or a new entry written on to an existing MAR sheet. A person may therefore have several MAR sheets, and some may start on different dates.

Verbal orders are not encouraged due to the potential for medication errors. However, in cases where verbal orders are taken, this must be from a qualified prescriber and must be documented by two individual care staff. A new prescription should then follow where appropriate or written confirmation should be sent by fax within 48 hours of the request being made, signed by the responsible prescriber.

On admission to hospital, the care home must send a copy of the MAR sheet, and other documents in the red bag that accompanies the individual.