1. This document gives CSCI inspectors a guide to good practice in how medication should be administered in care homes.

It covers:
" what the regulations and national minimum standards say
" what the issues are when residents look after and take their own medicines
" what are the equality and diversity issues that care providers need to consider
" what safeguards must be in place when care workers give medicines to residents
" why practice is different in care homes (nursing)
" the pros and cons of monitored dosage systems
" what to do about homely remedies
" what an inspector should look for.

This guidance is linked with the paper 'Professional Advice: Training care workers to safely administer medicines in care homes'. What do the regulations and national minimum standards say?

2. Regulation 13 (2) of the Care Homes Regulations 2001 requires the registered person 'to make arrangements for the …. safe administration …. of medicines' prescribed for residents.

3. National minimum standards for care homes include that the care provider:
" supports residents who wish to and are capable of self-administering their medicines to do so safely.
" provides care workers with a robust procedure to administer medicines to those residents who rely on them for this aspect of care.

4. The national minimum standard that applies to care homes (personal care) states that 'all medicines, including controlled drugs, (except those for self administration) are administered by designated and appropriately trained staff'.

5. The national minimum standard for care homes (nursing) states that 'medicines, including controlled drugs, for service users receiving nursing care are administered by a medical practitioner or registered nurse'.

What are the issues when residents look after and take their own medicines?

6. Prescribed medicines belong to the person they were supplied for, identified by the name on the label. The care home does not own them, even though care workers may request and take receipt of medicines. This applies whether or not the home provides nursing care.

7. Residents are free to choose whether or not to keep and take medicines themselves. This important element of resident choice promotes independence and dignity. If care providers chiefly promote administration of medicines by care workers, residents may not be aware of the support that can be offered to them. But it is important for care providers to assess any risk to the resident or others in the care home if they look after their own medicines. And part of the risk management strategy includes providing residents with somewhere secure to keep the medicines in their own rooms.

8. Residents who have a physical or mental disability should not have their medicines automatically given by care workers. Community pharmacists undertake assessments under the Disability Discrimination Act and may be able to adjust the way that medicines are packed or labelled for individual residents in order to promote self-administration. Examples include large print labels if their eye sight is poor, containers with ordinary caps instead of child-resistant closures that are difficult to open

9. Residents in care homes (nursing) have the same right to choose as those in care homes (personal) care. When a registered nurse gives care it does not automatically mean that residents may not look after their own medicines.

10. However, there are reasons why some residents do not choose to keep their own medicines, preferring instead to allow the care staff to take the responsibility for them. This is often the case for older people and when this happens the care provider should document resident choice.

11. There are situations when a resident is keen to look after some medicines and not others. An example is when a resident keeps an inhaler for immediate use but prefers the care workers to look after tablets and liquid medicines.

12. Care workers should identify whether residents who are confused or lack cognitive awareness can safely keep and take their own medicines. And this assessment should also consider how it affects the safety of other residents in the home.

Can care workers give medicines to residents?

13. Care workers may, with the consent of the resident, administer prescribed medication, so long as this is in accordance with the prescriber's directions (The Medicines Act 1968). And consent does mean that a resident may at any time refuse to take medication that the care worker offers. Residents will also have certain preferences and these may relate to equality and diversity. The following are of particular concern:
" The medicine is provided in a gelatine capsule and the resident is vegetarian
" Residents prefer to have medicines given to them by a member of the same sex
" The resident observes religious festivals by fasting and prefers not to have medicine given at certain times.

These specific examples of resident choice and preference should be recognised and accommodated through the care planning process.

14. In care homes (personal care), basic training is essential before a care worker gives medicines to residents. This should cover administration of the following:
" tablets and capsules
" liquids that must be measured, e.g. lactulose
" cream, ointment or other external application
" eye, ear or nose drops
" inhalers.

15. Many care providers allocate medicine administration to senior staff. But there must be enough suitably trained workers to cover all of the times that residents may need medicines. It is not in the best interests of residents to restrict access to pain relief during the night because care workers are not at a senior level.

16. When medicines must be administered by specialised techniques, the community nursing service supports people who live in care homes (personal care). With additional training from a healthcare professional, a care worker can give the following:

" rectal administration, e.g. suppositories, diazepam (for epileptic seizure).
" insulin by injection
" medicines through a Percutaneous Endoscopic Gastrostomy (PEG)
" oxygen.
(This is not an exhaustive list.)

17. This is very important when residents have medicines prescribed for conditions like epilepsy in care homes for adults. Some medicines are in tablet or liquid form that care workers can give. But when the resident has a seizure, he/she may need to have medicines administered rectally and this is a specialised technique. Seizures are not predictable, so it is impossible to predict when the medicines will be needed. And it is not in the best interest of the resident to delay treatment for a paramedic to attend the home. Delegation of administration to a care worker is an important aspect of care provision.

18. The care home's procedures must include that care workers can refuse to assist with the administration of medication by specialised techniques if they do not feel competent to do so.

What safeguards must be in place?

19. There are two important safeguards that care providers must make sure are in place to protect their residents:
" written procedure for the administration of medicines, which is monitored to make sure that care workers follow safe practice
" care workers have the correct level of training before giving any medicines. This is detailed in the publication 'Professional Advice: Training care workers to safely administer medicines in care homes'.

20. But a further safeguard is that care workers only give medicines to residents from the container that the pharmacist or dispensing GP has provided. This container must have the name of the resident on the label and the full instructions for the care worker to refer to. Re-packaging medicines into another container with the intention that a different care worker will give it to the resident at a later time is called 'secondary dispensing'.
Both the Royal Pharmaceutical Society and the Nursing & Midwifery Council state that this is unsafe practice that can potentially cause drug errors.

Why is there a difference between care homes that offer personal and nursing care?

21. A care home (nursing) employs registered nurses. The Nursing and Midwifery Council (NMC) Code of Professional Conduct requires each nurse to be individually accountable for making sure that all medicines are administered correctly.

22. Nurses may delegate the administration of some medicines to care workers. An example of this is the application of cream or ointment when the care worker is bathing the resident. But the administration of medicines by invasive or specialised techniques will normally involve a registered nurse.

Are monitored dosage systems essential in care homes?

23. Monitored dosage systems (MDS) have been promoted as a safe system of medicine administration in care homes. But MDS are merely a convenient form of packaging for a limited group of medicines. Safe practice is not guaranteed by use of a system alone but is promoted by only allowing staff who are trained and competent to give medicines.
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24. MDS do improve some procedures including:
" the system of organising repeat prescriptions for residents
" supply to the care home of printed medicine administration record charts (MAR)
" a visual check whether medicines have been prepared and given to the resident.

25. MDS can only be used for tablets and capsules. But there are exceptions and the following should not be put into MDS:
" medicines that are susceptible to moisture, e.g. effervescent tablets
" light-sensitive medicines, e.g. chlorpromazine
" medicines that should only be dispensed in glass bottles, e.g. glyceryl trinitrate
" medicines that may be harmful when handled, e.g. cytotoxic products like methotrexate.

26. Liquid medicines, creams, eye drops, inhalers must be supplied in traditional containers. Therefore, any care home that uses MDS will have two different systems operating.

27. Care providers must consider carefully how any changes that the prescriber makes to the resident's medicines can be obtained in MDS quickly. MDS work well when the resident's medication is regular and does not change frequently. Packaging of medicines for 'as required' use in MDS is not suitable.

28. There is a real issue of how MDS are financed. The NHS does not fund MDS systems such as Manrex, Nomad, Venalink, Medidose, Dosette and similar systems. The care provider may be asked to pay for the equipment. Suppliers of medicines (community pharmacists, dispensing GPs) cannot be compelled to provide medicines in this way however much the care provider may want it. Individuals can be assessed within the Disability Discrimination Act criteria for support to manage medicines themselves. This does not apply to entire care environments where the principal benefit is to care workers.

29. It is therefore not appropriate for CSCI inspectors to recommend or require the use of MDS or other compliance systems.

30. Some care providers who have been unable to get medicines in MDS have taken the decision to allow care workers to re-package medicines in similar products called compliance systems. Examples of these are Medidose, and Dosette. This is 'secondary dispensing' already referred to in section 20.

Can care workers give medicines that the doctor has not prescribed?

31. Many medicines can be purchased through wholesalers and retail outlets by anyone. Residents may decide to buy and keep remedies to take themselves, including herbal remedies and products that they purchase from other countries.

32. When the care provider keeps a range of 'homely remedies', it is care workers who will decide whether to give them to a resident or not. A definition of a homely remedy is treatment for mild to moderate symptoms that need immediate relief that people would use to self-treat if they were at home without consulting their GP, for example toothache or indigestion. These medicines are potent and may interact with medicines that the doctor has prescribed for residents.

33. The care provider is under no obligation to provide this treatment. But if homely remedies are purchased for occasional use by residents, the care provider must have a written policy that details the following:
" which medicines are kept for immediate relief of mild symptoms that a resident may choose to self-treat in their own home
" the indications for offering the medicines
" the dose to give and how often it may be repeated before referring to the resident's doctor
" how to establish with the resident's GP that the remedies will not interact with other prescribed medicines
" how to obtain the resident's consent to treatment that the doctor has not prescribed
" how the administration will be recorded.

34. If a problem such as constipation persists, residents should consult with their GP because the symptoms may be masking other medical problems. This is why homely remedy use should be time-limited.

Checklist for CSCI Inspectors

35. The policy and procedure for medicine administration should explain to care workers what to do and how to do it safely. Is there evidence to support that:
" care workers have read and understood the policy?
" the principles of the policy are part of everyday practice in the care home?

36. Resident choice should feature in arrangements for medicine administration. Some issues to investigate include:

" Does the care provider support residents to look after their own medicines?
" How is resident consent obtained and recorded when care workers give medicines.
" Has the care provider identified individual resident preference? This may include the time and place that he/she would prefer to have their medicines; and whether the resident prefers care from a same sex worker.

37. The care home should have evidence that care workers are trained before they are expected to give medicines. Please refer to 'Professional guidance: Training care workers to safely administer medicines in care homes'

38. Useful sources of information that will identify whether medicines are given correctly to residents include:
" MAR charts within the care home. Please refer to 'Professional guidance: Medicine administration records (MAR) in care homes and domiciliary care'
" direct observation of a 'drug round'
" what residents say about their medicines
" whether there are reports to the commission about serious incidents involving medicines
" whether there are complaints to the commission involving medicines.