POLICY FOR THE CONTROL OF MEDICINES IN RESIDENTIAL AND

CHILDREN’S HOMESISSUED BY: Shalim Salam

Pharmaceutical Adviser Enfield Primary Care Trust

In consultation with:

Enfield Social Services

Enfield and Haringey Local Medical Committee

Enfield & Haringey Local Pharmaceutical Committee

FOR ADVICE, CONTACT: The prescribing team 020 8272 5718/5719/5547/5726

Enfield Social Services020 8447 9980

Enfield Primary Care Trust (Revised March 2004))

ROYAL PHARMACEUTICAL COUNCIL STATEMENT

ISSUED AFTER DISCUSSION WITH THE BRITISH MEDICAL ASSOCIATION

Associations With Medical Practitioners And Other Health Care Professionals

The Council of the Royal Pharmaceutical Society has issued the following statement on professional co-operation between Pharmacists and General Practitioners (GPs). It replaces the statement that appeared in 'The Pharmaceutical Journal' of December 17, 1988 (p782).

Close professional co-operation between Pharmacists and GPs is to be encouraged in the interests of all concerned, most of all the patient. However, a Pharmacist should not enter into any association with a GP that may compromise his own professional independence.

A patient issued with a prescription that is to be dispensed at a pharmacy has the right to present it for dispensing at any pharmacy of his choice. This helps to ensure that no undesirable business relationship develops between a GP and a Pharmacist, whereby one can exercise undue influence on the other, and it also demonstrates to the public the independence of each profession.

Pharmacists must not approach GPs or their staff to secure direction of prescriptions to a particular pharmacy.

A prescription should only be sent direct from a medical practice to a pharmacy when:

the patient has requested the direction, or

the patient is in residential care and has indicated his wish that the person providing that care may collect or receive prescriptions on his behalf, or

the patient is an addict receiving medication by instalments.

A GP shall not offer or give inducements to any person in consideration of his supplying to the Pharmacist, either:

prescriptions for medicines or appliances for patients, orEnfield Primary Care Trust (Revised March 2004) 2

orders for medicines other than those for use by a GP in his practice.

Ref: The Pharmaceutical Journal, April 22 1989, p478

CONTENTS Page

1. RESIDENTS' SELF-ADMINISTRATION 4

2. PRESCRIBING OF MEDICATION 6

3. STORAGE OF MEDICATION 8

4. DOCUMENTATION 9

5. ADMINISTRATION OF MEDICATION 11

6. DISPOSAL OF MEDICINES 13

7. HOMELY MEDICINES 14

8. STAFF TRAINING 20

9. PHARMACEUTICAL SERVICES 20

10. IMPLEMENTATION, MONITORING AND REVISION 22OF POLICY

APPENDIX 'A' 23

APPENDIX ‘B’ 26

Enfield Primary Care Trust (Revised March 2004) 3

APPENDIX ‘C’ 30

REFERENCES 31

Enfield Primary Care Trust (Revised March 2004) 4

CONTROL OF MEDICINES IN RESIDENTIAL HOMESNot all residents will be able to retain and administer their own prescribed medication, but it is desirable that in those deemed capable, this should be encouraged. In making decisions about medication practices within the home, proper arrangements should be made for the safekeeping, administering and disposing of drugs and medicines. Where residents administer their own drugs, facilities should be provided for the safe keeping of medication in a personal, lockable drawer or cupboard. Drugs for which the home takes responsibility should be kept in a secure place in individual containers, fully labelled with name and dosage and administered by a trained responsible person.

AIM

To ensure medicines are used in the most appropriate way for all residents to meet their individual needs, and to enable them to have an informed choice in the light of the GP's instructions and their own wishes.

The definition of “children” for the purposes of the various relevant legislation relates generally to those who are under the age of eighteen years. It is also the policy within the various Acts that all children should be treated, where possible, as they would normally be in their own homes. The guidance states that children over the age of sixteen would normally be considered responsible for their own medication. Some children, for example, those using inhalers, will need to be responsible for their own medication at a younger age.

In order to clarify the status of items in this Policy the word 'must' has been reserved for legal requirements.

1. RESIDENTS' SELF-ADMINISTRATION

1.1 Service users should be involved in deciding to take responsibility for their own self-medication if they wish under a risk management framework. A documentary record should be kept by the home signed by the, service user and home manager/owner as evidence that the user is competent to look after there medication needs. The record should be sent to the GP to sign at a convenient time, (see appendix A)

1.2 Children over the age of 12 keeping and administering their own medication should be assessed by staff as sufficiently responsible to do so. Children over twelve should be encouraged to self administer inhalers etc. and insulin under supervision if appropriate.

1.3 Residents self-administrating medicines should be provided with a lockable space in which to store medicines away from other residents. This should be made accessible to suitably trained, designated home staff with the service user’s permission.

1.4 The resident should be encouraged to inform the home staff of medication, and notify them if any changes in medication have been prescribed. It may be appropriate for the resident to carry an individual medication record detailing current medication. See 4.1 regarding documentation.

1.5 Where a resident is considered capable of self-administration of medicines, it is not the responsibility of the home's staff to ensure that medication is taken as prescribed. However, the staff should continue to have a semi-supervisory role and should notify the GP if there is reason to believe that the resident is failing to take the medication as directed. It may also be appropriate for the Pharmacist supplying the medication to the resident to monitor the supply and to advise the home's staff or the resident's GP of non-compliance if necessary.

1.6 The ability of the resident to self-administer medication should be reviewed regularly The review should involve appropriate professionals eg social worker, home manager/owner etc. It is appropriate for the GP to confirm over the telephone, once every three months , that a patient could continue to self administer.

1.7 Service users who are admitted for short-term care either planned or as an emergency, to receive an opinion from GP may not always be possible. Therefore home must ensure the service user, next of kin if appropriate and manager signs and states that the service user takes responsibility to self medicate.

2. PRESCRIBING OF MEDICATION

2.1 All medicines must be prescribed for individual residents by the GP, in accordance with their Terms of Service. Where medication is prescribed by the hospital, the details of the medication should be sent to both the resident's GP and to the manager of the home.

2.2 Provided the GP agrees residents may retain their own GP. If the resident cannot or does not wish to make the choice, the manager may advise on registering with a GP.

2.3 Prescribed medications are only given to the residents for whom they were prescribed in accordance with the prescription and not kept for general use for other people (children or staff) or added to ‘stock’ for such use.

2.4 Prescriptions will normally be for no more than 28 days.

2.5 On no account should staff be involved in writing prescriptions, and FP10 forms should not be left in the home.

2.6 The manager or designated responsible person should ensure continuity of supplies by requesting repeat prescriptions for residents when necessary.

2.7 Staff should ask the GP to put full instructions on the prescription. GPs should avoid the use of "as before" or "as directed", although for the use of insulin and warfarin “as directed” may sometimes be appropriate. "When required" medication should specify the dose, the time of dose and the time interval between doses.

Occasionally a more flexible approach to "when required” medication may be necessary. In these cases the prescription should state "To be taken as required in accordance with written instructions left by the doctor". This should be clearly discussed with the GP so that the manager of the home is aware of the circumstances whereby “when required” medication should be administered. The GP should provide clearly written, signed and dated instructions in the home with either the patient or the manager which can then be recorded in the individual medication record or care plan.

2.8 Medication should be reviewed by the GP as clinically appropriate. Such reviews will be conducted either at consultation with the individual or consideration of the patients repeat medication list. GPs should sign repeat prescriptions with access to their practice computer system.

2.9 When a resident attends an outpatient department, day centre, or is admitted to hospital, great care should be taken to ensure that there is no confusion regarding any changes in medication. There should be full consultation between the manager, the GP and Pharmacist on their return to the home.

Drugs held by the residents are their responsibility and are not covered by the following guidance about drugs held centrally.

3. STORAGE OF MEDICATION

3.1 Residents who self-administer their own medication should be given a personal secure locked place in which to store their medication safely.

3.2 All other medication, including external preparations and reagents (such as urine testing products), should be stored in lockable wooden or metal cupboards or trolleys, and preferably kept in a room not normally accessible to residents. If medicines are stored in a trolley then, when not in use, this should be secured to an immovable object, such as a wall.

3.3 Medicine cupboards and trolleys should be kept locked at all times except when medication is being issued or received. The keys should be carried by the manager or the designated responsible person. A procedure for handing over keys should be understood by all staff concerned.

3.4 Keys for medication cupboards and trolleys should be kept separate from other keys.

3.5 Controlled drugs (CDs) - the GP and the Pharmacist supplying medication to the home should be asked to inform the manager when a controlled drug is supplied for any resident. All homes should use a controlled drug book and ensure two staff witness and sign when drug is administered.

The manager should refer to the Pharmacist supplying the medication, for the advice on storage, each time a CD is supplied. It may be necessary to store CDs separately from other medication.

3.6 All medicines should be kept in the containers in which they were dispensed. ON NO ACCOUNT should medicines be transferred into other containers unless it is part of a self-administration programme that should be discussed and agreed with your local pharmacist. For these patients, there should be clear written guidelines of the process by which this takes place for the individual resident in the home. (See section on self-administration).

3.7 For those medicines requiring refrigerated storage, a dedicated refrigerator should be used. The refrigerator should contain a

maximum/minimum thermometer, and temperatures should be recorded on a daily basis. Storage temperature must remain within 2-8 oC. Records should be retained for 3 years.

4. DOCUMENTATION

The care home owner/manager has a statutory responsibility for the appropriate maintenance of records and the manner in which records will be kept. These must be kept up to date and should be checked against the current prescription rather than the previous chart.

4.1 The following records must be kept by the home:-

Medicines Book or other similar document to record the ordering, receipt and disposal of medicines for all patients. All medicines ordered and received should be recorded in the medicines book except those kept personally by residents. Individual items should be recorded along with the name of the resident for whom they are prescribed and the details of the disposal of any unused medicines should also be entered. This will ensure accountability in the cases of accidental overdose or misappropriation by unauthorised persons.

Medication profile or record card for each individual resident including those self-medicating, detailing all prescribed medication in chronological order. The GP should be asked to verify the medication at their next review of the patient. The medication record should contain:

a) The residents name and date of birth.b) Name of general practitioner;c) Details of any known medicine sensitivity e.g. to penicillin or aspirin; d) Any information provided by the pharmacist on foods that might react with the prescribed medicine;e) Full details including the name, date medication started and discontinued, quantity, dose, form, strength and method of administration of medicines;f) The date of receipt of the dispensed medicine;g) The times at which the medicine should be given.

In large residential homes, administrative records will normally be designated to record each dose given. If a controlled dosage system is used, this may not be necessary - instead there should be 'exception reporting' when a dose is not administered.

In smaller homes (<12 residents), 'exception reporting' may also be suitable, but each home wishing to undertake this type of reporting should discuss it with the PCT prescribing team.

The administration of 'homely medicines' should always be recorded. A 'homely medicine' cannot be administered for more than 48 hours without the GP being informed. If the conditions worsen after administration of the homely

medicine, contact the GP immediately.

An administration record is not required for residents who self-administer their own medication, although for some, this may be a useful compliance aid. It may be advantageous to carry out regular counts on medication, with the resident's agreement and participation. This does not apply to children where full records must be kept.

4.2 It is advisable to keep the medication profiles and the administration records together with the medication, so that they will be available for inspection each time medication is administered.

4.3 The medication record card should remain in the home at all times, and be available to record prescribed medication at the time of consultation. Consideration must be given to supplying a duplicate medication record card in cases of absences from the home i.e. holidays and hospitalisation.

4.4 The medication record card should be available for inspection by authorised officers of the NCSC, the GP responsible for the care of the patient, the pharmacist supplying the medicine and other appropriate officers.

4.5 The medication record card should also be available for

inspection by the resident on request.

4.6 For Residential Homes (and not Children’s Homes), completed medication record cards should be kept with the resident's notes. The cards should be retained for three years after the death / discharge of a resident. The cards should be stored within the home. For Children’s Homes, the above applies except the period of retention is fifteen years after the last entry on the record card.

5. ADMINISTRATION

5.1 The homeowner or manager should appoint a ‘designated person’ to look after the medication needs of residents within the home when service users are unable to manage their own medicines. Such persons should be appropriately trained and assessed as competent to undertake this role.

In residential homes, members of staff responsible for administering medicines (day or night) should be clearly identified as designated responsible persons by the Home Manager. Such persons should be appropriately trained for the role. In those establishments providing professional nursing care, a first level nurse should administer medication. They should be familiar with this document and the Nursing and Midwifery Council regulations.

5.2 The manager of the home, or the designated responsible person, should ensure that all medicines are administered strictly in accordance with the GP's instructions. If it is unclear what the GP's intentions are, then this should be clarified with them before administration. If any problems occur with medication, e.g. adverse reactions, advice should be sought from the Pharmacist or from the resident's GP.

5.3 Medicines are the property of the resident for whom they are prescribed and should never be used for the treatment of anyone else.

5.4 Medication must never be used for social control. It should be recognised, however, that medication is sometimes given for psychiatric or behavioural disorders but in every case, there should be constant surveillance and review.

5.5 Medicines should always be administered to the individual resident directly from the original dispensed containers bearing the Pharmacist's label. In large homes, this may be impractical, and homes should consider a Controlled Dosage System - (see Appendix A).

5.6 The label on a dispensed medicine, supplied by the Pharmacist, should not be altered under any circumstances. If the GP alters the dose, the Pharmacist should be asked to re-label. If the label becomes detached from the container, or is illegible, the advice of the Pharmacist should be sought. The GP can alter the label and initial the alterations, as an emergency measure. A new label must be obtained within 24 hours.

5.7 The medication should be checked against the medication record card immediately before administration and, if possible, by a

second person. Only if the information is the same on both, should the medicine be administered. Any discrepancies should be referred to the Pharmacist or to the GP.

5.8 Recording of the administration of medicine should be made at the time of administration. If a Controlled Dosage System is used, only non-administration of regular medication needs to be recorded. Carers should record the reason for refusal of the dose so that that this can be appropriately discussed at the time of a medication review with the GP and/or pharmacist. This is included as a standard for Children’s Home.

5.9 The manager, or the designated responsible person, should liase with other health care staff such as District Nurses, to ensure that appropriate records are maintained in the home regarding the administration of, e.g. enemas, suppositories, medical dressings, antibiotic sprays, creams and injections.

5.10 A resident prescribed insulin injections may be able to self-administer the injection. However, home staff should ensure that an appropriate professional arrangement is made if the resident becomes unable or unwilling to self-administer.

5.11 All other injections should be administered by the GP or District Nurse unless other arrangements have been made after discussion with the GP. Authority to administer injections by patient, carer or registered nurse should be obtained in writing from the GP, stating the patient's name, drug to be administered, dose and to whom the authority has been delegated, and dated.

5.12 The best way of administering medication to a service user is directly from dispensed container, medication can be placed in a small pot after removing it from the dispensed container as a way of hygienically handling it to the service user.Medication should never be secondary dispensed for someone else to give to service user at a later stage.

5.13 The home must seek immediate advice from GP or Pharmacist

when medication is administrated in error to a service user.

5.14 Any adverse drug reaction or suspected reaction should be reported to the GP and / or supplying pharmacist for that individual service user and discussed further administration of drugs in question.

6. DISPOSAL OF MEDICINES

6.1 All medicines are the property of the resident, or in the case of children, it may be the legal guardian. The resident, guardian or their next of kin’s permission should be sought before disposal. Medicines should be disposed of when:

the expiry date is reached, or

a course of treatment is completed or discontinued, or

the resident for whom they are prescribed leaves the home, or

the resident for whom they are prescribed dies.In such cases, the medicines should be retained for seven days following the death in case they are required by the Coroner's office.

6.2 Medicines for disposal should be returned to a community pharmacy participating in a local pharmaceutical waste scheme.

6.3 Medicines should never be discarded in dustbins, or flushed down the sewerage system. Under no circumstances must medicines be disposed of on the premises as this is prohibited by current Waste Authority Regulations.

6.4 The return of medicines to the Pharmacist should be authorised by the manager or designated responsible person and an appropriate entry made in the medicines' book and witnessed.

6.5 ON NO ACCOUNT should medicines be retained or used for other residents.

6.6 Pharmacist must sign home records when medication returned to chemist.

7. HOMELY MEDICINES

7.1 A 'Homely Medicines' list is intended to meet a recognised need to treat minor ailments without necessarily consulting with the resident's GP.

7.2 Set out below is a range of conditions or symptoms considered appropriate for this type of medication.

Constipation Cough Mild pains Diarrhoea Indigestion Mild skin conditions

7.3 Homely medicines should be administered to the residents at the discretion of the officer in charge. The doses that may be administered should be agreed between the pharmacist and home manager.

7.4 Staff are advised not to treat children under six years of age.

7.5 It is recommended that homely medicines be purchased from the pharmacy that provides the service to the home, so that full dosage instructions are on the label.

7.6 Prescription only medicines (POMs) must never be stocked.

7.7 Written advice regarding the use of homely medicines must be recorded on the resident's medication record. Treatment should not extend beyond two days without medical advice being sought.

7.8 Staff administering homely medicines should be suitably trained for the role.

7.9 Residents should be encouraged to inform home staff of any medicines purchased by themselves, and appropriate advice should be given. If such medication is taken regularly, a record should be made on the medication record card.

7.10 Arrangement should be reached between the PCT prescribing team, the local pharmacist and the home as to the appropriate products to be made available.. The following list is a

recommendation only.

7.11 Consideration should be given to those residents of ethnic minority groups who may wish to use their native 'homely medicines'.

7.12 Homely remedies must not be labelled for an individual if they are to be administered to several service users.

CONSTIPATIONConstipation may be corrected by increasing the amount of fibre in the diet, increasing fluid intake and encouraging mobility. Some drugs can induce constipation so check any new medication with the Pharmacist.

The use of laxatives in children is undesirable, and the introduction of fruit purée in the diet may be sufficient to regulate bowel action.

LACTULOSE

Suggested stock level - 500 ml

Dose: Adult 15 ml twice a day gradually reducing according to the patient's needs.

Child (6 - 12 years) 10 ml twice a day gradually reducing.

Lactulose should be taken regularly and may take up to 48 hours to act. If constipation persists, consult the GP.

Side-effects

Flatulence, cramps and abdominal discomfort.

COUGHPersistent cough or a chesty cough accompanied by green sputum or chest pain or sputum containing blood should be referred to the GP. Some prescription drugs can cause dry cough as a side effect, so check the patient's medication with the Pharmacist.

SIMPLE LINCTUS / SIMPLE PAEDIATRIC LINCTUS

Suggested stock level - 200 ml

Dose: Adult 10 ml three times a day and at night

Child (6 - 12 years) Same dose of paediatric linctus (preferably a sugar free formulation).

If the patient is diabetic, consult the GP.

PAIN (mild e.g. headache)If pains are severe, consult the GP.Please note, for conditions in children where the temperature rises above 1010 F (38.50 C) despite tepid sponging and paracetamol, contact the GP.

PARACETAMOL TABLETS 500 MG ( SOLUBLE ALSO AVAILABLE)

Suggested stock level - 50 tablets

Dose: Adults Two tablets every four hours when required (not more than eight in twenty four hours)

Child (6 - 12 years) 250 mg to 500 mg (i.e. half to one tablet) repeated every 4-6 hours when required (not more than four in twenty four hours).

Precautions

Check the resident is not taking any other pain killers containing paracetamol, or 'over the counter' pain killers or cold remedies which may contain paracetamol. Your Pharmacist will be able to advise you.

DIARRHOEAThe first line treatment in acute diarrhoea is the prevention or treatment of fluid and electrolyte depletion. This is particularly important in children and the elderly. If the patient has severe or watery diarrhoea, the GP should be contacted within 24 hours. If mild to moderate diarrhoea persists beyond 48 hours, contact the GP.

REHYDRATION SALTS (E.G. DIORALYTE, REHIDRAT)

Suggested stock level - two packs of six sachets with instruction leaflet.

Dose: The contents of one sachet to be dispersed in 200 ml of water and given after each loose motion. (Read instruction leaflet)

N.B. Diarrhoea may occur as a side effect of some antibiotics or other drugs. Consult the Pharmacist for advice.

INDIGESTION/HEARTBURNIndigestion is likely to be brought on by heavy and/or fatty meals, eating too quickly, smoking cigarettes and drinking alcohol. Persistent tummy pain should be reported to the GP.

MAGNESIUM TRISILICATE

Suggested stock level - 200 ml

Dose: Adult 10 ml three times a day in water in between meals

Child (6 - 12 years) Half the adult dose

For heartburn, take immediately after food.

Side effects: Too much can cause loose motions/diarrhoea.

N.B. Antacids can reduce the effect of some prescription drugs - check with the Pharmacist.

SKIN COMPLAINTS

CLEANSING AGENTS

NORMAL SALINE SACHETS (Normasol)

Suggested stock level - 1 pack of 25 sachets

Used to clean a minor cut or abrasion. Either pour the contents of the sachet directly onto the wound or use some clean cotton wool.

BRUISING

ARNICA CREAM

Suggested stock level - 1 x 27g tube.

Apply gently to the bruised area following the manufacturer's instructions.

Precautions: Severe cuts and bruises, cuts and bruises in diabetics, or residents on steroid treatment, should be reported to the GP.

CREAMS AND OINTMENTS FOR SORE SKIN (maximum 2 products)

Application: Staff should wash hands before and after applying creams and ointments.

AQUEOUS CREAM

Suggested stock level - 1 x 100 g tube

A useful moisturiser for dry skin.

CREAM E45 Suggested stock level - 1 x 50 g tube

A non-greasy softening / soothing unperfumed cream. Useful for dry or chapped skin.

WHITE SOFT PARAFFIN (VASELINE)

Suggested stock level - 1 x 120 g

Barrier ointment, soother and softener.

SUNBURN

CALAMINE LOTION

Suggested stock level - 200 ml

Precautions: if sunburn is severe seek medical advice.

MINOR BURNS AND SCALDS

Bathe area in running cold water for at least ten minutes. If in any doubt seek medical help, as burns can become infected.

FIRST AID REQUIREMENTS FOR STAFF

First aid boxes for employees must comply with the Health and Safety (First Aid) regulations.

8. STAFF TRAINING

8.1 The pharmaceutical aspects of staff training should be the responsibility of the home's management, with help and advice from the Pharmacist providing the service to the home. In England the National Minimum Standards set out requirements for training of care staff in homes for older people and adults The standards require that such training be accredited.

It should be monitored by the PCT prescribing team.

8.2 The home’s policy should state how frequently training is given. Regular courses will be organised in each home to initiate new members of staff and review established staff. All staff training should be documented.

8.3 Members of staff responsible for administering medicines should be identified as designated responsible persons and be appropriately trained for the role.

8.4 A recent addition of the British National Formulary should be available in each home, as a reference book for designated officers to assist staff in their appreciation of residents' medication. This should be used discriminately and any questions raised, discussed initially with the Pharmacist or the individual patient’s GP.

9. PHARMACEUTICAL SERVICES

9.1 Residents have the right of choice as to where their prescriptions are dispensed. For those residents who are unable to exercise their individual choice, it is desirable that the home should deal with one conveniently situated local pharmacy. For children under the age of sixteen, it is not appropriate for them to collect medicines from a pharmacy unless accompanied by a carer or guardian.

9.2 It is the responsibility of the Pharmacist to provide medical products and appliances on National Health Service prescription forms, or on private prescriptions.

9.3 The PCT prescribing team is responsible for ensuring that advice on storage, supply and administration of medicines is available. The advice is given by the pharmacist supplying the home, who would visit the home regularly.

9.4 All dispensed medicines should be supplied in suitable containers with printed labels. The labels should include:-

Name of resident Date Name of medicine Full dosage instructions Quantity of medication (e.g. number of tablets) Additional cautionary and advisory labels as appropriate.

Medication supplied to the larger homes, should, preferably, be in a controlled dosage system or as recommended by the PCT prescribing team. The costs of these systems are not covered by the prescription fees and the pharmacist may charge the home for setting up a controlled dosage system.

9.5 The Pharmacist supplying medication to the home should notify the officer-in- charge on storage of CDs.

9.6 All prescriptions should be dispensed promptly to ensure medication is available at the correct time for each resident.

9.7 If a resident attends a day hospital, training centre, etc., it may be necessary to have the lunchtime dose dispensed separately.

9.8 Where a child’s time is divided between the family home and a children’s home, careful liaison must take place between all the health professionals involved in the health and welfare of the child.

9.9 The Pharmacist supplying the home should, if possible, maintain up to date records of all residents' medication. Any anomalies which arise from multiple prescribing, over-dosage, possible drug interactions or adverse reactions should be notified to the GP and the home manager.

10. IMPLEMENTATION, MONITORING AND REVISION OF POLICY

Managers of homes should review their systems for supply, storage, administration and disposal of medicines and, if necessary, obtain further advice from the PCT Pharmaceutical Advisers.

Written guidelines for the control of medicine will be prepared and be available for reference in each home.

All dual homes are inspected regularly by the National Care Standards Commission.

Regular visits by the Pharmacist, providing a service to the home, should be undertaken to provide advice on adherence to the policy.

The PCT Pharmaceutical Advisers will monitor the implementation of the policy recommendations.

The policy will be reviewed regularly and revised as appropriate in consultation with all those concerned.

APPENDIX 'A'

CONTROLLED DOSAGE SYSTEMS

A Controlled Dosage System is a method of packaging medicines whereby each dose is individually dispensed for each patient. The two main systems in operation are the Nomad System which involves packaging the medication into a plastic cassette or the Manrex System in which the medication is sealed into a foil sheet.

Both of these systems operate on a 28 day cycle therefore, any homes considering using a Controlled Dosage System should arrange with the GP for a 28 day supply on all repeat prescriptions.

The pack is only suitable for tablets and capsules.

MEDICAL RECORDS

A form for use with the Controlled Dosage System, or for use in the small homes, where exception recording (ie only recording where patients do not take their drugs) would be sufficient, is also attached. Each form should be used in conjunction with the "Medication Round Record Chart".

For residents self-medicating, a resident's monitoring chart should be used.

Controlled drugs.

The Misuse of drugs Act 1971 is the legislation governing Controlled Drugs. The

majorityof controlled drugs are prescribed on NHS prescription for individual

named serviceusers. It must be hand written by GP and state in both words and

figures the quantity anddose.

Storage of controlled drugs.

Controlled drugs for service user who are not self-medicating must be stored in

cupboard meeting the requirements of The Misuse of Drugs Regulations 1973.

This should be a metal cupboard secured to the wall. The drug

cupboard should only be used for the storage of controlled drugs.

Administration and records of controlled drugs.

The administration of controlled drugs by authorised staff members should be witnessedby another designated- trained members of staff. Care homes must keep a separate record of controlled drugs receipts, administration and disposal. These records must be kept in a bound book. Must include balance remaining for each product and separate record page used for each service user.

Oxygen

A home can choose to purchase a supply of oxygen, it is most commonly obtained on a prescription for individual service users. Oxygen can be kept in the individual service user’s room taking account of relevant safety advice and displaying the appropriate safety notices. The pharmacist who supplies the oxygen equipment is responsible for its servicing and upkeep.All rooms where oxygen is in use should display the statutory warning

notices: NoSmoking, No Naked Lights.

Refusal and Covert administration.

It is an individual’s right to refuse medication. Carers should record the reason for

refusal so that it can be discussed with GP. When a service user is considered incapable of giving consent to treatment, or where the wishes of a mentally

incapacitated service user appears contrary to the interests of the person, the GP

responsible for treatment should be consulted. They should consult relatives / carers

and other members of the multi- disciplinary team on any action to be taken.

There may be certain circumstances in which covert administration may need to be

considered to prevent a service user missing out on essential treatment.

Any decision must be reached after assessing the care needs of the service user. In

residential homes for older people, the manager, relative, GP and social worker must

sign the covert medication agreement form (see Appendix ‘C’)Alternative formulation of medicine should be considered e.g. liquid

preparations. Under the Medicines Act 1968 only medical and dental practitioners can authorise the use on ‘unlicensed’ medicines in humans. The opening of capsules and crushing of tablets makes their use unlicensed. It should only be carried out if the prescriber authorises it in writing and the person administering the drug has no concerns about the pharmaceutical effects of the drug. A community pharmacist would be able to provide the necessary information.

Appendix ‘B’:Self Administration of Medicines.

Managing the risks to you and others.

All those who wish, and who are able, to manage their own medication will be encouraged to do so. In order to achieve this, a number of steps have to be taken to minimise risks to residents wishing to self-administer medicines and to others around them.

1. Minimising risks to you. In the first instance we need to establish that you are able to manage your own medicines. It may be that you wish to do everything from ordering repeat prescriptions through to taking the medicines yourself. Alternatively, you might want or need staff assistance with a part of this process.We will also need to ask your next of kin or other representative along with your GP to provide an opinion on your ability to manage your own medicines. The home's manager will then sign to confirm that you can manage your medicines and will keep the attached completed form on your file. This arrangement will be reviewed at least every three months.You will be asked to provide the home with details about your medicines and to keep the home's manager informed of any changes to your prescribed medicines.

2. Minimising the risks to others. It is essential that you keep all your medicines secure by locking them either in a cupboard or drawer within your bedroom. This is to ensure that there is no risk of other residents inadvertently taking your medicines. The manager of the home will keep a spare key to your lockable furniture.

To be completed in all cases where residents wish to self-administer medicines.

1. For completion by the resident.

I …………………………. confirm that I wish to manage my own medicines. I am able to self administer/order prescriptions (delete as appropriate) and agree to ensure my medicines are kept safe in lockable furniture within my bedroom.

Signed …………………………

2. For completion by next of kin or other representative.

I ………………………… can confirm that ………………………… is able to self administer medicines and agree to periodically reviewing this arrangement with the home's manager.

Signed …………………………

3. For completion by GP.

I Dr ………………………… can confirm that ………………………… is able to self administer medicines and agree to periodically reviewing this arrangement with the home's manager.

Signed …………………………

4. For completion by home manager.

I ………………………… agree that, based on the opinions of the resident, their next of kin (or representative) and the GP, the above named resident is able to administer their own medicines.

(Continued)

Signed ………………………… Name …………………………Date ……/……/20…..Self Administration of Medicines Review.

Resident's name …………………………

Review date

Reviewed by Review outcome Comments

Risk Assessment - Self Administartion of Medicines

HAZARD CONTROLResident self administers wrong medicine or dosage or fails to take medicines

Multi-disciplinary assessment of ability - see self administration agreement form

Other residents gaining access to medicines To be stored in lockable bedroom furniture

Appendix ‘C’: COVERT MEDICATION AGREEMENT FORM

Name of service user ………………………………………………………………..

Reasons why medication needs to be administered covertly and risks if service user does not take the medication

………………………………………………………………………………………….

………………………………………………………………………………………….

………………………………………………………………………………………….

Medication Dos Frequency

Reason for medication

Covert method of administering medication …………………………………………

…………………………………………………………………………………………

Action to be taken if medication is still refused, spat out etc.

…………………………………………………………………………………………

…………………………………………………………………………………………

Date agreement is to be reviewed:

Signed …………………………………

(Residential Home Manager) Date:

Signed ………………………………..

(General Practitioner) Date:

Signed …………………………………..(Relative/Carer/Advocate) Date: Please state relationship…………………

Signed …………………………………..Social Worker Date:

REFERENCES

1. The Administration and Control of Medicines in Residential and Children’s Homes

The Royal Pharmaceutical Society of Great Britain, June 2003.

2. National Care Standards Commission. www.carestandards.org.uk, 7/3/2003