HM Medical Clinic

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Cialis ne doit pas être prise à tous. Il est important que cialis en ligne est prescrit par un médecin, bien se familiariser avec les antécédents médicaux du patient. Ich habe Probleme mit schnellen Montage. Lesen Sie Testberichte Nahm wie cialis rezeptfrei 30 Minuten vor dem Sex, ohne Erfolg. Beginn der Arbeiten nach 4 Stunden, links ein Freund ein trauriges Ja, und Schwanz in sich selbst nicht ausstehen, wenn es keinen Wunsch ist.

Medication Policy
(example document for e-learning course)
Roles and Responsibilities 2.1 Registered Manager 2.2 Care Staff (Nurses & Senior Care Workers) Training and Competency 3.1 Basic training in safe handling of medicines 3.2 Specialised training to give medicines Ordering medicines from a Pharmacy 4.1 Repeat prescription requests for the GP 4.2 How to check the prescription on return from the GP 4.3 How to check medicines delivered from the pharmacy 4.4 Obtaining acute medicines 4.5 Verbal Orders Medication Administration Records (MAR Charts) 5.1 Purpose of the MAR chart 5.2 New admissions and contents of MAR charts 5.3 The MAR chart must 5.4 The MAR chart must detail 5.5 Audit of MAR charts 5.6 Respite residents and MAR charts 5.7 Use of MAR charts 5.8 As required (PRN medication) 5.9 Variable doses 5.10 Transfer to another setting 5.11 Changes in medication 5.12 Discharge from hospital 5.13 Verbal instructions to change medication or doses 5.14 Retention of MAR chart records Storage of medicines 6.1 Self-administering residents 6.2 Non self-administering residents 6.3 Medication requiring refrigeration 6.4 Storage of controlled drugs 7.1 Covert administration 7.2 Procedure for administration of medicines 7.3 Administration of controlled drugs 7.4 Re-dispensing medication Disposal of medicines Page 1 of 32
Medication Labels 10.0 Record Keeping 10.1 Records for controlled drugs 11.0 Self-administration for residents 12.0 Medication Errors 12.1 Mistakes in administration 12.2 First Error 12.3 Second Error within a 6 month period 12.4 Third Error within a 6 month period or a serious medication error 13.0 Holidays and Short breaks 14.0 Unidentified Medication 15.0 Administering of insulin, injections, enemas, through a PEG tube
16.0 References
Appendix 1:
Annual Assessment of Competency to Administer Medications Guidelines for Good Practice – Oral Medications Discrepancies of Medications from the GP Discrepancies in Monthly Medications from the Pharmacist Verbal Orders being given by Medical Health Professionals Medication Transfer Form Self-Administration Medication Risk Assessment Form Self-Administration by a Resident (Agreement) Medication Risk Assessment Form Medication Investigations Guidance Medication Investigations Form 1st Staff Error Form 2nd Staff Error Form 3rd or Serious Staff Error Form Medication Temperature Monitoring Log for Fridge Treatment Room Temperature Monitoring Log Medication Audit Medication Induction Training Pack New Resident Notification of Medication to Pharmacy Form Staff Signature Sheet – Responsible for Med Administration Covert Medication documentation Page 2 of 32
This policy has been written in accordance with Regulation 13 of the Health & Social Care Act 2008 (Regulated Activities) Regulations 2010. The corresponding Outcome 9 (Management of Medications) will be upheld through the practical application of this policy. Care Quality Commission (CQC) Outcome 9: Management of medicines, states that people using a service regulated by CQC:  Will have their medicines at the times they need them and in a safe way  Wherever possible will have information about the medicine being prescribed made  available to them or others acting on their behalf. This is because providers who comply with the regulations will:  Handle medicines safely, securely and appropriately  Ensure that medicines are prescribed and given by people safely  Follow published guidance about how to use medicines safely. 2.0 Roles & Responsibilities
The Registered Manager
2.1.1 It is The Registered Manager's responsibility to:  Ensure that safe systems of ordering, receipt, storage, administration and disposal of medicines are in operation within the care home.  Ensure safe custody of all medicines (including controlled drugs) within the care home.  Ensure that the assistant manager on duty is trained to take responsibility for management of medicines within the home, in their absence.  Recognise that medicines are the property of the resident, and they should be given the choice of controlling their own medication.  Ensure that all care staff involved in medication administration have received training appropriate for their level of administration, and competency assessments.  Ensure medication records are maintained and kept for the required period of time.  Ensure that there is a system in place to ensure adequate supplies of medication are always available. Nurses and Senior Care Staff
2.2.1 It is the responsibility of staff to:  Follow the care plan and this policy.  Provide the level of support specified in the care plan:  Provide support (which includes administration of medications) in accordance with the Page 3 of 32
care plan and the prescriber's instructions.  Follow the procedure for administration of medicines and the use of MAR charts.
 Record medication administration/assistance on the MAR chart provided.
 Be alert to factors which might pose a risk to the resident, and report concerns to the
Registered Manager. If the Registered Manager is not available, concerns may be reported to the assistant manager on duty. Concerns reported may include the accuracy  Immediately report any mistakes in the administration of medication to the Registered Manager or Deputy Manager on duty, including omitted doses.  Ensure that all medication errors are reported as incidents within 24 hours using the Incident Reporting form.  To promote self-administration where appropriate.  Document refusal of medication by resident. 2.2.2 Nurses/ Senior Care Staff are only accountable for medication they themselves administer or assist with and will be known through this document as Nominated Persons/ Registered Manager/ Deputy Manager. Training & Competency
3.0.1 The training provided for Registered Managers, Deputy Managers and Nurses and Care Staff must incorporate the requirements of this policy. 3.0.2 The Registered Manager must ensure that a record of training for medication administration is available for every staff member responsible for the administration of medication. This must include the date the training was completed and the name and signature of the trainer. Annual competency assessments in medicines administration are to be completed for all staff responsible for the administration of medication. This annual competency assessment must be documented and signed off by both the staff member and the Registered Manager. This training record must be made available for inspection by the Care Quality Commission (CQC) Inspectors upon request. Basic training in safe handling of medicines
3.1.1 Nursing staff and Senior Care Assistants must not be permitted to give support with medication until they have:  Received training in company policy and procedure regarding medicines  Been assessed as competent by the Manager/Deputy/ Designated Competent Mentor of the care home upon completion of the Medication Induction Training Pack  In the case of senior care workers: they have undertaken or are undertaking level 3 safe handling of medication. Page 4 of 32
3.1.2 Competencies should be:  clearly defined  assessed consistently  re-assessed annually 3.1.3 All nominated persons responsible for administering medication will be subject to an Annual Assessment of Competency to Administer Medication. It is the Registered Manager's responsibility to ensure that this is done annually and relevant actions taken forward. 3.1.4 The essential elements of training are:  How to prepare the correct dose of medication for ingestion or application.  How to administer medication that is not given by invasive techniques, including tablets, capsules and liquid medicines given by mouth; ear, eye and nasal drops; inhalers; and external applications.  Training on controlled drug administration. Care home workers required to ‘witness' controlled drug administration must also have received this training.  The responsibility of the Nurse/ Senior Care Assistant to ensure that medicines are administered only to the person that they have been prescribed for and to ensure that these medicines are given as prescribed i.e. the right dose, at the right time and by the right method/ route.  Checking that the medication ‘use by' date has not expired.  Ensuring that medication is being stored correctly (e.g. refrigerated products).  Checking that the medication has not already been given by anyone else.  Recognising and reporting possible side effects.  Recording refusals to take medicines.  How a care home worker should administer medicines prescribed ‘as required', for example pain killers, laxatives.  What care home workers should do when people request non-prescribed medicines.  Understanding the service provider's policy for record keeping.  How to report a medication administration, recording, storage or disposal error. Specialised training to give medicines
3.3.1 Medicines management must be discussed regularly in individual supervision sessions and at staff meetings to check care home workers understanding on medicines management training and to provide support to individual care home workers. The Registered Manager should encourage staff to openly discuss any training needs which they feel have not been addressed during their period of training. 3.3.2 Weekly spot checks of MAR charts completed by newly trained Senior Carers or Newly Appointed Nurses are to be undertaken by the Registered Manager to ensure that the care home worker is competent in the medicines administration and recording procedure. The Page 5 of 32
check will be a balance and signature check on the MAR chart and will take place for a period of one month. The competency form should be completed as necessary. 3.3.3 If, at any time, the Registered Manager has concerns about the competency of a Nurse or a Senior Care Assistant with regard to the medication procedure, they should follow the Medication Investigation Proforma at Appendix 10b and Guidance at Appendix 10a. All medication is potentially dangerous and should be handled with extreme care at
all times.
Ordering Medicines From a Pharmacy
4.0.1 Resident's medication should be reviewed by their GP/pharmacy every six months. This should be logged on the 6 Month Medication Review Form located in each resident Care File. The Registered Manager is responsible for ensuring that staff are competent in ordering repeat prescriptions for residents. 4.0.2 The Registered Manager should ensure the staff are trained to manage medication effectively, this wil involve giving the dispensing pharmacy ful details of a resident's medicines (al regular medicines and "when required" – prn - medicines) as soon as possible/ before prescription forms are sent for dispensing utilising the pharmacy (Appendix 15):  They initially take up residence  They return from a period in hospital  There is any change to the medicines prescribed 4.0.3 This allows the pharmacy to note the medicines in anticipation of the prescription, and note if any special orders apply. 4.0.4 It is the responsibility of the Senior or Nurse to make sure that the pharmacist is aware of any allergies or sensitivities to mediation. Repeat prescription requests for the GP
4.1.1 The Registered Manager of the care home must ensure that staff manage medication effectively and that repeat medication from the monthly cycle are ordered two weeks in advance of them being required to allow time for generating the prescription, collection and checking by the home prior to being sent to pharmacy for dispensing. All medication must be checked, including topical preparations, eye/ear drops and inhalers to ensure they are ordered when required. All residents must have a 28 day supply ordered to ensure medication is always available. 4.1.2 Medication is re-ordered every 28 days . The Registered Manager or, in their absence, the Deputy Manager on duty is responsible for ensuring that the delegated staff are competent in this area and the task is completed accurately. 4.1.3 The current MAR chart must be checked for accuracy against the repeat medication form FP10 (attached to the previous month's prescription). Items required are ‘ticked' off, adding any additional items recently prescribed or not documented. Both the GP Repeat Ordering Page 6 of 32
Form FP10 and Pharmacy Repeat Ordering Form should be used. Copies are to be made and filed in individual pockets. 4.1.4 Stock levels of homely remedies(where used and verified as being agreed by GP) should also be checked to maintain supplies for the next month. If there are sufficient medicines to last for the next month, a new order must not be placed. 4.1.5 It is unacceptable to return unused medicines each month to the pharmacy, and at the
same time request more supplies.(this does not apply in the case of low numbers of
medication that may have been a result of non-administration over the cycle)
4.1.6 The original order sheet must be sent to the surgery in a stamped addressed envelope. The care home must keep a copy of the order.(this must be retained in an individual pocket for the resident). This may vary in each home depending on the local agreement in place with the GP and pharmacist How to check the prescription on return from the GP
4.2.1 All newly issued prescriptions from the GP must be checked against the copy of the FP10 order retained by the home. All details below must be correct:  Personal details – name, DOB  Each medication - name, strength and dosage, frequency of administration and amount of tablets  There must be the appropriate amount of medication to last the full 28 day cycle 4.2.2 Any discrepancies must be completed on the ‘Discrepancy of Medication from GP Form' and queried with the surgery in question (Appendix 3), immediately upon discovering the discrepancy. The outcome must be documented on this form. 4.2.3 A copy of the prescription must be taken and retained by the care home. The original is then sent to the pharmacy for dispensing. The copy of the prescription is then to be maintained along with the copy FP10 order in an individual pocket. How to check medicines delivered from the pharmacy
4.3.1 The pharmacy will deliver the dispensed monthly medication in locked cases which must be kept in a locked cupboard in the medication room until the contents have been checked in by the nominated staff members. The community pharmacy must indicate if there is a refrigerated item in the delivery and this item must be checked in and refrigerated immediately. All medicines dispensed from a community pharmacy will have a pre-printed MAR chart with them. 4.3.2 All medication must be checked, by two members of staff, one of which should be a Registered nurse or senior carer, the copied prescription and the new MAR chart. The current MAR chart should then be checked against the new MAR chart which came with the medication. All details below should be checked: Page 7 of 32
 Personal details – e.g. name, DOB, GP, any allergies, week commencing  Each medication - name, strength and dosage of medicine  Any specific instructions regarding storage or administration, e.g. store in fridge, take an hour before food etc.  The quantity of the medication received e.g. 28 tablets 4.3.4 If there are discrepancies, these should be recorded on the ‘Discrepancy in Monthly Medications from the Pharmacy Form' and queried with the pharmacy. (Appendix 4) 4.3.5 The amount of medication received must be entered in the appropriate box on the MAR chart, signed and dated by the 2 competent staff. If the pharmacy does not deliver the full amount of medication, the competent person, must follow this up with the pharmacy immediately and obtain an estimated date of delivery. The Registered manager must be 4.3.6 Where pharmacy advises there is a manufacturing problem, it is the responsibility of the nominated person to follow this up by:  Identifying if/when the medication will be available  Liaising with the GP to provide an alternative medication.  Ensuring the prescription for the alternative is subject to normal checking  Ensuring the prescription for the alternative is available in a timely manner to ensure the resident does not have any period without medication. The resident must not be left without medication at any time.
4.3.6 Resident's individual control ed drugs should be entered into the care home's control ed drugs book by a nominated staff member on duty and witnessed by a second person. Controlled drugs must not be put into a monitored dosage system (MDS) by the community Obtaining acute medicines
4.4.1 When a prescription is written for a medicine that the person has not had before or does not take regularly, it is an ‘acute' supply and must be started as soon as possible, and within 24 hours at the latest. Acute medication is usually for a limited time such as five or seven days. The nominated person must contact the dispensing pharmacy immediately to arrange supply. If the GP is to supply the medication it must be in the original packaging, or have been packed down for use by a registered pharmacy, with a label for the GP to complete the name of the patient, date and any dosing instructions. Verbal orders
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4.5.1 When a prescriber or other healthcare professional requests a verbal instruction to alter a patient's medication, please refer to 5.11.2. A ‘verbal orders' form must be completed for al verbal orders of medication by GPs(Appendix 5) and must be witnessed and countersigned by another senior staff member. To further evidence this, a fax, email or confirmation in writing must be obtained within 24hrs, this is then to be copied, one copy to care file, one copy to be maintained with MAR. Medication Administration Records (MAR CHARTS)
Purpose of the MAR Chart
5.1.1 The MAR chart is the formal record of administration of medicines. It is required for all residents receiving medicines, and may be used as evidence in clinical investigations and court cases. It is therefore important that they are clear, accurate and up to date. 5.1.2 The episode of a resident self-administering their own medication must be recorded in the care record. Medication balances for those residents self-administering their medication must be checked on a monthly basis to ensure that residents are taking their medicines and that they have sufficient supply. This can also be discussed with the resident at their monthly 5.1.3 A MAR chart is a confidential record which should only be shared with others with the resident's, or their representative's, permission. 5.1.4 The MAR chart must provide an accurate account of the medicines being administered to the resident by the care home staff. It should document all prescribed medicines, including external y applied medicines and dressings with a legal classification of ‘prescription only' (POM), if applied by a nominated person. 5.1.4 All staff trained to administer medication must do so as per policy and procedure whilst respecting their own governing body alongside which policy and procedure sits. Charts must be maintained in a manner that provides an accurate representation of the medication dispensed, administered and taken by the resident with no omissions. New residents to the care home and contents of MAR charts
5.2.1 For all new residents (long term, short term, transfer from hospital or inter-unit transfer within the home or unit to unit), medicines reconciliation should be completed by the nominated staff member to ensure that all medication a resident is currently taking is accurately documented. All handwritten MAR Charts must be checked and signed by 2 nominated staff 5.2.2 The nominated person/ Home Manager must reconcile at least two reliable sources of information available at the time. Sources might include, for example:  Resident's supply of label ed medicines  Discharge prescription  GP summary Page 9 of 32
 Repeat prescription  The resident/carer  MAR chart. 5.2.3 Resident-held records should be checked where applicable e.g. warfarin, methotrexate. 5.2.4 The nominated person must ensure that the medicines are suitable for use by checking expiry dates and that the pharmacy issued labels attached to the medicines show the resident's name etc. Unfamiliar medicines or doses must be checked and unusual doses should be confirmed with the appropriate prescriber or pharmacist before writing on the MAR chart and before administration of the medicine takes place. Where medicines are labelled ‘as directed' this must be attended to immediately, the correct dose must be established, in the event that it is a PRN medication a ‘PRN' protocol is to be developed. 5.2.5 The MAR chart must only be written by the nominated person and check by a second competent person on duty if no computer printed MAR chart is available. 5.2.6 A new prescription must be requested from the GP as soon as possible. 5.2.7 The nominated person must advise the community pharmacy of the resident's current medication, including any ‘PRN' medicines. The MAR chart must:
 Be clear, written in indelible and permanent ink.  Only include items which are still being currently prescribed and administered.  Include all externally applied medicines to be administered by care home staff. The MAR chart must detail:
 The resident's details
 Known allergies
 The name and form (e.g. tablets, capsules) of all medicines that are to be
administered or applied by the care home worker  The time they must be given (e.g. breakfast, lunch, tea and bedtime)  The dose  The route, if not to be taken by mouth, e.g. ‘to be inhaled'  Any important special information, e.g. store in the fridge, take an hour before food, specific instruction for Alendronic acid, risedronate to be maintained with MAR and  The names of those preparing the MAR chart and the date prepared  The quantity of the medication received  If more than one chart is in use, reference to the other charts, e.g. ‘chart 1 of 2'.  PRN medication as a cross reference to the PRN medication chart and PRN protocol Page 10 of 32
 An up to date photograph of the resident (attached to the MAR chart and medication folder) to assist nominated staff with identification Audit of MAR charts
5.5.1 The Registered Manager must have a system in place for a nominated individual within the care home to audit all MAR charts. The MAR chart audit must check for:  care home workers signatures, ensuring that there are no gaps  cross referencing with the remaining balance of each medicine  MAR charts should be checked at handover and documented that this is the case. 5.5.2 The outcome of the audit is to demonstrate that all residents receive their medication as 5.5.3 All MAR charts are to be checked on a daily basis for missing signatures by the Registered Manager, Deputy Manager or nominated person. If signatures are missing, the procedure described in section 12 of this document must be followed. Respite Residents
5.6.1 Medicines for a respite resident should be:  Counted in at the beginning of the resident's stay and counted out at the end of the period of respite  Re-ordered if there are insufficient medicines to cover the period of respite  Re-ordered if the respite stay is extended  Recorded on the MAR chart, signed by the nominated person, witnessed by a member of staff who has been trained in medications administration and dated. 5.6.2 The information on the MAR chart must exactly match that on the prescription form, or the dispensing label, provided by the doctor, pharmacy or hospital dispensary. Use of MAR Charts
5.7.1 Each time a dose of medication is due, the nominated person administering it must follow the instructions step by step. 5.7.2 The nominated person must immediately record the administration of a dose by signing the MAR chart in the correct place and should never sign until the medication has been given 5.7.3 Prescribed medication not given must be clearly recorded using the appropriate code on the bottom of the MAR Chart and recorded overleaf on the ‘Carer's Medication Notes' of the 5.7.4 The information on the MAR chart will be supplemented by information recorded in the resident's care plan/care record. 5.7.5 It is important that MAR charts which are no longer in use (e.g. MAR charts dating from previous months) are removed and segregated from the current charts filed with Page 11 of 32
corresponding order and copy of prescription and maintained in calendar order to provide a complete audit trail. 5.7.6 Should a resident refuse medication on 3 consecutive occasions the nominated staff must seek advice from the GP and then document any advice given and action taken. As Required (PRN) Administration
5.8.1 Nominated persons must not assist with administration of these medicines unless there are specific instructions in the form of a PRN protocol in which clarifies the following:  What the medicine is being used for e.g. pain/anxiety/agitation  The minimum interval between doses  Maximum number of doses in 24 hours  Quantity of medication to be given (dose) 5.8.2 Nominated persons must inform their manager if there are not enough instructions. 5.8.3 Nominated persons must:  Always check the time of the previous dose in order to ensure that it is within the minimum time interval specified by the prescriber.  Record the date and time the dose was administered  Record the current balance remaining after each dose has been administered.  Contact the resident's doctor, if o The resident wishes to take prn medication more frequently than prescribed o Consumption increases markedly o They have reason to believe the medication is not effective for the resident. 5.8.4 If prn/as required medicines are used infrequently, it is important to check before  That the medicine was originally prescribed for the purpose for which it is now  That the resident is not taking any new medication that might interact with or duplicate the action of the prn medicine. If in doubt, check with the doctor or  That it has not been replaced by a more recently prescribed prn or regular medicine  That the supply is still in date, bearing in mind that some medicines have a shortened expiry date once opened. Check pack for details. If in doubt, refer to a pharmacist for Variable Doses
5.9.1 Resident's Choice – If a variable dose of a medicine is prescribed (e.g. one or two tablets to be taken, as required, for pain) the decision regarding the dose to be taken rests with the resident and the prescriber. Page 12 of 32
5.9.2 Nominated persons must ask the resident how much of the medication they wish to take. If the resident is unable to decide, or respond, nominated persons should request specific instructions from the prescriber. Variable doses should not be prescribed for residents who do not have capacity to make the decision. Nominated persons are not permitted to assist with the administration of these medicines unless and until a decision has been made by the resident or the prescriber regarding the dose to be taken and in the event of the resident not having capacity, a capacity assessment has been completed around this decision. 5.9.3 Clearly record on the MAR chart the number of tablets/amount of liquid taken, underneath the administering signature. Warfarin requires extra caution: The dose of warfarin to be taken varies according to the results of the resident's most recent blood test. It is important to take great care to administer the correct dose of Warfarin. The dose to be taken wil be recorded in the resident's yel ow, anticoagulant record book following their most recent blood test results. Blood tests are carried out regularly (they can be weekly, fortnightly or monthly as requested by the GP or consultant). The warfarin drug and dose must be written onto the MAR chart. If a yellow, anticoagulant record book is not available, dosage directions from the anticoagulant clinic nurse or doctor must only be accepted in writing (a fax or email is OK), signed and dated by the prescriber. The written confirmation must be filed in the resident's care plan and up to date copy with the MAR Chart and must correspond with the directions on the MAR. The warfarin yellow, anticoagulant record book must always accompany the resident when attending the Warfarin clinic for review. Changes to the dose of Warfarin prescribed must be recorded on the MAR chart by the nominated person, and checked by a second person trained in Medicines Administration. The MAR chart must be signed by both persons. 5.10 Transfer to another setting
5.10.1 A copy of the current MAR chart, PRN chart and any remaining medication belonging to the resident are to be sent with each resident when transferring to another care setting or when being admitted to hospital. This is to ensure continuity of care for the resident. The Registered Manager should ensure that a record of medicines sent with the person is completed and checked. Please see the Medication Transfer Form at Appendix 6. The following should be recorded:  Date of transfer  Name and strength of medicine/s  Quantity/ies of medicines Page 13 of 32
 Medicines requiring refrigeration/maintenance of the cold chain  Signature of the care home worker arranging the transfer of medicines.  Running stock balance of medication.  Controlled drugs must be physically handed over and counted by the person receiving who then countersigns the controlled drug register. The Medication Transfer Form can also be used when the resident is being transferred from the Care Home to a home address. 5.11 Changes in Medication
5.11.1 The care home must have a system to check the accuracy of any changes in medication. 5.11.2 When a resident's medication is altered the GP must issue a new prescription and the nominated person is responsible for ensuring that the MAR chart is amended as follows:  The original medication and instruction for administration are cancelled with a written entry to say why this has been actioned in the resident's care record and the name and designation of the GP who altered this.  The new prescription to be sent to pharmacy on receipt from GP as per agreed terms with pharmacy (faxed/collected)  If a visiting GP changes a resident's medication, they should be asked to write the details on the MAR chart, sign and date the change. The GP should also be asked to record details of the new instructions in the resident's care records. If the GP is unable to fulfil these tasks, the nominated persons may complete this as described  New medication should be requested by the Registered Manager, or the assistant manager in their absence, from the pharmacy as a matter of urgency. 5.12 Discharge from Hospital
5.12.1 When a resident leaves hospital, even following a short stay, it is likely that changes will have been made to their medicines. 5.12.2 The Registered Manager, Deputy Manager alongside the nominated person must ensure that the previous MAR chart is reviewed against the discharge prescription and updated following discharge from hospital. 5.12.3 The labelled supply of medicines sent home with the resident and the discharge summary of medicines from the hospital is the authority to administer those medicines and supersedes any previous MAR chart. Page 14 of 32
5.12.4 Medicines should be administered according to the instructions on the label and discharge summary. Any additional medication is to be entered onto MAR as previously described. It is good practise to liaise with the discharging ward to determine if there are any changes to medication whilst in hospital, if there have not been changes advise the ward it is not necessary to dispense medication if it is already on site. Where there have been changes to medication, the procedure re handwritten entries is to be followed. 5.13 Verbal Instructions to Change Medication or Doses
5.13.1 Under exceptional circumstances, the Registered Manager may accept verbal instructions
to change or stop, one day's treatment only if the prescriber is unable to do so directly,
 The Registered Manager/ Deputy Manager/ Nominated Person receives the instruction first hand from the doctor or other prescribing healthcare professional and careful y records the details of the conversation in the care record and on the ‘verbal orders' form'. (refer to Appendix 5)  The Registered Manager/ Deputy Manager/ Nominated Person must ensure the prescriber follows up verbal instructions in writing as soon as possible, within 24hrs.  The Registered Manager/ Deputy Manager/ Nominated Person must double check full understanding of the instructions received by reading them back to the authorising doctor or other prescribing healthcare.  The Registered Manager/ Deputy Manager/ Nominated Person must record the time and date of the conversation  The Registered Manager/ Deputy Manager/ Nominated Person must record the name of the authorising doctor or other prescribing healthcare professional  The prescriber and the Registered Manager/ Deputy Manager/ Nominated Person must involve the resident as much as possible to ensure they are aware of, and consent to, the change. Residents should understand that they may check the actions of care home workers when administering medications to them at any time.  The Registered Manager/ Deputy Manager/ Nominated Person must ensure the MAR chart is not amended, as the verbal instruction applies to a single day's treatment
only. Any regular change to medication must be made on receipt of written authorisation from the doctor or other prescribing healthcare professional.  The nominated person must record the dose given in the GP Communication Sheet with a cross reference on the MAR chart to the care record, (e.g. ‘see GP Communication Sheet')  All entries are to be countersigned by a witness and if possible verbal instruction over the phone are to be shared with two members of senior staff. 5.14 Retention of MAR chart records
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5.14.1 The MAR chart must be retained in the care home's current MAR chart folder whist in use. 5.14.2 Any MAR chart no longer in use (e.g. from a previous month) must be removed promptly and segregated from the current charts. The MAR is to be filed with the copy FP10 order and copy prescription to ensure an audit trail from order, receipt to administration is maintained. 5.14.3 Used MAR charts must be retained by the care home for a minimum of 7 years. Storage of Medicines
Self-Administering Residents
6.1.1 All medicines should be stored in the resident's own room in a locked cupboard. 6.1.2 The keys must be kept in the resident's and/or carer's possession at al times. 6.1.3 A spare key should be kept by the home in a secure place. Non Self-Administering Residents
6.2.1 All resident's medicines are stored in a locked medicine trol ey which, when not in use, must be securely fixed to the wall. 6.2.2 The keys to this trol ey must be kept secure at al times, in the nominated person's 6.2.3 All medicines must be kept in the packaging in which they were obtained from the pharmacy 6.2.4 Stock medication will be kept in locked cupboards in a locked room, where the temperature should not exceed 25 degrees centigrade. Room temperatures are to be recorded daily. 6.2.5 Internal medication e.g. tablets, must be stored in different cupboards from external medication e.g. creams. 6.2.6 Nutritional supplements and dressings must be stored in a lockable room. 6.2.7 Medicines supplied in monitored dosage systems, needing more storage space to cover the change-over period each month, must be locked away until needed in a locked cupboard in a 6.2.8 The keys to the stock drug cupboards and room should be kept secure at all times in the possession of the nominated person. 6.2.9 The keys to the controlled drug cupboard must be kept separate to the keys for the drug cupboard that the controlled drug cabinet is held within. The Registered manager must ensure that an effective system is in place to support this. Medication Requiring Refrigeration
6.3.1 Must be kept in a locked medication fridge, maximum and minimum thermometer, within a 6.3.2 The Registered Manager for the care home has overall responsibility for maintaining the cold chain of refrigerated products. The Deputy Manager on duty must be responsible in the Registered Manager's absence. Page 16 of 32
6.3.3 The medicine fridge must not store anything other than medication, no food or samples should be stored in it. 6.3.4 Monitoring of fridge temperatures must take place every day by reading and recording the temperatures displayed by the integral maximum and minimum fridge thermometer. The readings should remain between 2 and 8 degrees centigrade. The maximum, minimum and current temperature should be recorded every day by the nominated person and must be recorded on a temperature monitoring log form. (Please see Appendix 12). 6.3.5 Any temperature that falls outside the 2 to 8 degrees centigrade range must be reported immediately to the Registered Manager who will decide on the action to take by getting advice from the supplying Pharmacist. If necessary, the supplying pharmacy should make arrangements to repair or replace the fridge. Until instruction has been given regarding medicines in the fridge, stock within that fridge must not be used. A notice should be attached to the fridge stating ‘stock in quarantine – do not use until further notice'. The notice should be dated and should direct enquiries to the Registered Manager or the Deputy Manager on duty. 6.3.6 The refrigerator requires defrosting and cleaning in accordance with the manufacturer's recommendations or sooner in the case of spillages etc. Storage of Controlled Drugs
6.4.1 Controlled drugs must be stored in a locked controlled drugs cupboard which is bolted to a solid wall and only used for the storage of controlled drugs. 6.4.2 The keys for this cupboard must be kept secure at all times in the possession of the nominated person. The keys to the controlled drug cupboard must be kept separate to the keys for the drug cupboard that the controlled drug cabinet is held within. The Registered manager must ensure that an effective system is in place to support this. 6.4.3 The care home cannot purchase and keep stocks of controlled drugs. 6.4.4 A weekly check of resident's own control ed drugs is to be carried out by the nominated person and checked as being completed by the Registered Manager, signed in red. 6.4.5 A weekly check of Prn controlled medications should take place once a month by the Registered Manager or their deputy and one other trained person. A monthly check should be made on all daily controlled medications. 6.4.6 When a resident is self-administering controlled drugs, the drugs are to be stored in the care home's controlled drugs lockable cupboard. The care home will make the necessary arrangements for the administration of the controlled drug(s) to the resident at the appropriate time. No one should be deprived of receiving controlled drugs because only one member of staff is on duty when the resident requires it. 6.4.7 If any medicine cupboard keys become lost, including the keys to the controlled drugs cupboard, the Registered Manager should be informed immediately. The Registered Manager is responsible for investigating this incident fully, an incident report form must be Page 17 of 32
completed and the Police, the Care Quality Commission and Local Safeguarding Team must be advised if deemed necessary. 7.0.1 Medicines must only be administered in accordance with the prescriber's specific 7.0.2 Nominated persons may only assist with administration of medicines that have been correctly label ed by a pharmacy with the resident's ful name and date of dispensing. The medicine name, prescribed dose and frequency should also be included except where the dose is variable and given in accordance with separately written instructions e.g. warfarin 7.0.3 Medicines must not be given after their expiry date. Note: many medicines have a reduced expiry date after opening. Check pack for details. If in doubt, ask the pharmacist for advice. 7.0.4 If oral liquid medicines need to be measured by a syringe, a designated oral syringe must be 7.0.5 Nominated persons should have access to appropriate, up to date information about the medications they are to administer, for example the British National Formulary (BNF). The Registered Manager is responsible for ensuring that the supplying pharmacy provides this every 12 months for every Treatment Room. 7.0.6 Medication may only be administered to the resident for whom it is prescribed and in accordance with prescribing instructions. Only use a MAR chart that has had the medication details added by a Registered Manager, Deputy or nominated person or a registered healthcare, prescribing professional. Nominated persons must never tamper with the instructions on the MAR chart which are printed and provided by the pharmacist. 7.0.7 Where nominated persons are required to administer medicines that are considered a risk, a medication risk assessment should be undertaken of those medicines that must be "handled". Examples include external applications such as steroids, and cytotoxic medicines such as methotrexate. (Appendix 9) 7.0.8 If a resident's medication is dispensed in a monitored dosage system (MDS) by the pharmacy, and the medication is then changed by the GP, a completely new prescription must be requested from the GP, and the MDS returned to the pharmacy so that a new MDS 7.0.9 Tablets must not be crushed or dissolved, or capsules opened, unless it is stated to do so on the dispensing label. It is the responsibility of the Registered Manager to satisfy themselves that where there are such instructions the: Efficacy of the medication is not altered. That the resident is aware that the medication is being crushed./dissolved/opened, where the resident does not have capacity this will be managed as per covert medication. Where residents have serious difficulty in swallowing, the problem can be discussed with a pharmacist who will be able to find out if a suitable liquid product is available. This could be a liquid version of the original medicine or a different medicine that has the same effect. In Page 18 of 32
either case this will have to be discussed with the GP, prescriber and pharmacist. All parties should confirm in writing that it is acceptable to crush/ dissolve medications. 7.0.10 Staff must minimise interruptions prior to medication administration and if possible
ask a colleague to answer resident's bells and resident's needs unless an emergency
situation arises. The use of red labelled tabards can be implemented.
Covert Administration
7.1.1 Medicines must not be administered covertly to any resident who is deemed to have capacity to make a decision about whether or not they wish to take medication. If a resident refuses medicines offered, the nominated person must provide them with information about the medicine, which may enable the resident to reconsider their decision. Medication must not be given, or withheld, as a way of influencing or control ing a resident's behaviour. 7.1.2 The nominated person must try to ascertain the reason for medication refusal and record this on the MAR chart using the appropriate code and inform the Registered Manager. The refusal must also be recorded in the care record along with the reason why, if this is known. 7.1.3 The Registered Manager will contact the prescriber for advice (where refusal falls within part of a course of treatment, the GP needs to be informed after the 3 consecutive refusals). The GP is responsible for deciding what action is required. Continual problems or difficulties with medicines compliance must be discussed with residents, the staff team, family and carers where appropriate and their GP. 7.1.4 If a resident declines medication that is essential to their health and well-being, the GP must be informed immediately and the resident's mental capacity to consent or refuse medication must be assessed in accordance with the Mental Capacity Act. The resident's GP may be involved with this assessment. If the resident is assessed as capable to make their decision, their right to make this choice must be respected. This must then be documented within medication care plan. 7.1.5 If it is agreed by all parties that medication should be given covertly, (best interests decision)
this must be clearly documented in the resident's care plan stating the method to be used. Al residents who are given medication covertly must have this agreement reviewed at the monthly care plan review meeting. In the event that covert medication is only required occasionally, all entries where the medication has been given covertly must be clearly documented on the MAR. The relevant documentation in regard to covert medication should be used. Please refer to Appendix 17. 7.1.6 For crushing of medicines – refer to section 7.0.9 Procedure for Administering Medication
7.2.1 If there is any doubt or inconsistency, the medication is not to be given until it has
been checked and confirmed to be correct or professional advice has been sought.
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 Care home workers must wash their hands prior to giving medication.  The MDS or trolley must be taken to the resident.  If the medication is kept in a locked fixed cupboard away from the resident, the medicine must be dispensed at the cupboard and taken to the resident.  Only one MDS or similar should be taken to one resident at a time.  The correct MAR chart must be selected.  The resident's name, photograph, al ergies, medication, dosage, time on the MAR chart and pharmacy label must all be checked. The date on the MAR chart must also be checked and a check that the medication has not previously been given.  The nominated person must select the medication required and confirm that it is still current by checking the expiry date on the dispensing label, or the expiry date on the box or packaging.  The medicine must be removed from the pack/container/bottle supplied by the pharmacy and placed into a suitable dispensing pot to avoid contact with hands.  Liquids must be dispensed into a 5ml measuring spoon or graduated measuring pot. Doses less than 5mls must be measured using an oral medicine syringe. Metal
spoons should not be used.  Tablet cutters must be used to cut tablets; it is the responsibility of the Manager to ensure that the pharmacy has supplied these.  When dispensing PRN medication, care home workers must check the PRN protocol and be happy that the reasons documented for giving PRN are representative of the symptoms displayed by the resident. The time and date when the medication was last taken and if appropriate to give a further dose. After administration to the resident, remaining tablets must be counted and recorded on the PRN chart. Nominated persons must ensure that the actual amount taken is recorded on the MAR chart.  The MAR chart and resident's photograph should always be taken to the resident to ensure that nominated person's check that the photograph matches the resident and that the tablets are signed when taken.(photographs must be updated regularly and be a clear resemblance of the resident)  The medication should be given immediately to the resident addressing them by  If the medication is to be taken orally, the resident must be standing or sitting as upright as possible, and have a glass of water available or in line with the guidelines for specific medication such as milk.  The resident must be observed taking the medicine. Dispensed medication must not be left with the resident to take later.  If a topical preparation is applied for a resident, plastic gloves must be worn.  The MAR chart should be signed using the appropriate codes. Page 20 of 32
 If a resident refuses medication, the reason must be recorded using the appropriate coding and recorded on the reverse of the MAR Chart. If necessary, the GP should 7.2.2 It is unacceptable at any time to:
 Leave the medication trolley/cupboard unlocked and unattended in a public area.  Leave the medication keys in a unit cupboard etc, they must always be held by the nominated person administering the medication.  Leave medication unattended e.g. in a resident's bedroom or on a dining room table.  Pass the medication to another care home worker to take to the resident on your  Transfer medication from its original dispensing pack into an unsealed container for administering at a later stage or by another person.  Not sign the MAR chart at the point of administration.  Sign the MAR Chart when medication has not been administered or before it has Administration of Controlled Drugs
7.3.1 Nominated persons should follow the procedure for administering all medication:-  Two nominated persons must complete the entire medication administration process  The controlled drug register must be used to record all transactions with controlled drug medication, this includes: a. Receipt of controlled drug medication. b. Administration of controlled drug medication c. Removal of controlled drug medication- whether for disposal or for discharge with  All entries must be made in black ink, 2 members of qualified staff must be involved, and who both must check and sign the controlled drug register.  The index page at the front of the register must be completed for each individual controlled drug that is present at the care centre for each resident. This index is cross referenced with the numbered page that the actual entries are made. Good practise is to document the page on the MAR  The controlled drug register must contain the following information at the top of each a. Name of the controlled drug .e.g. Morphine Sulphate b. Strength of the controlled drug e.g. 10mg. c. Form of the controlled drug e.g. tablets. Page 21 of 32
 Only 1 sheet must be used per resident. If there are 3 residents that have been prescribed morphine, then each should have a separate page within the controlled drug register. When 1 page is finished, then the next blank numbered page is used in the controlled drug register. The corresponding page would be marked in the index next to the existing page number.  If any controlled drug medication is received then the following details must be a. Date medication was received. b. Time medication was received. c. Name of pharmacy that has supplied the medication. d. Quantity of medication that has been received. (this must be counted and e. Signatures of 2 members of qualified staff that have received this medication. f. Running stock balance of medication  If controlled drug medication is administered then the following details must be a. Date medication was obtained and checked. b. Time medication was obtained and checked. c. Residents name. d. Quantity of medication that is to be administered. e. Signatures from 2 members of qualified staff that have obtained and checked f. Running stock balance of medication carried out by 2 members of qualified N.B. the mar sheet is signed to indicate that the medication has been administered.  The entry must be checked with the instructions on the resident's MAR chart and with the label on the medication container.  The controlled drug book must be signed by two, appropriately trained members of staff completing the activity.  The MAR chart must also be signed by both nominated persons who completed the medication administration activity.  Liquid controlled drugs must be measured using an oral dispenser (syringe & bottle stopper) which can be obtained from the dispensing pharmacy.  Any discrepancies must be reported immediately to the registered manager.
The stock balance must reflect the actual quantity of medication that is present in the controlled drugs cabinet at any time. Each time medication is put in or taken out of the controlled drug cabinet an entry must be made within the controlled drug register.  This entry will be made by 1 member of qualified staff; a second member of qualified staff will check the medication and countersign the register. The 2 members of Page 22 of 32
qualified staff must be involved at the point when the controlled drugs are added or removed from the controlled drug cabinet.  It is not acceptable for a second person to countersign the controlled drug register who has not actually checked the item of medication which has been added or removed from the drug cabinet.  Weekly audit counts must be carried out by 2 nominated persons. 7.3.2 In the event of missing controlled drugs the Registered Manager must be contacted  The Registered Manager, with the person who has discovered the discrepancy, must check the date of receipt of the controlled drug and the amount of tablets / liquid entered into the controlled drug book.  This amount is then checked against the subsequent entries for administration of this  If it is still calculated that there is a shortfall, the Registered Manager must investigate  If there are facts that lead to a suspicion of theft, the police, CQC, Local Authority Contracts Department and Local Safeguarding Team must be informed.  An incident report form must be completed. Re-dispensing Medication
 Medicines should never be removed from their original container until the time of  If a resident is leaving the care home either permanently or for a period of time long enough to "miss" taking their medication at the expected time, they should take the medicine containers (MDS or bottles) with them.  The Registered Manager must ensure that all medication that is removed from the home is documented and the MAR is updated to reflect this. 7.4.1 Nominated persons should ensure:  The appropriate code is entered on the MAR chart.  Medication is checked on return to ensure medication has been taken by the resident.  The remaining quantity is recorded on the MAR chart and this is correct with no medication missing. 7.4.2 Repackaging medicines into another container with the intention that a different nominated person will give it to the resident at a later time is called secondary dispensing. Both the Royal Pharmaceutical Society and the Nursing and Midwifery Council state that this is unsafe practice which can potentially cause drug errors. Taking a tablet / capsule from its Page 23 of 32
original container and putting in a medicine pot for immediate administration to the resident is not classed as secondary dispensing. 7.4.3 Whoever removes, or decants, medication from its original container must oversee the administration of the ‘decanted' medication. The responsibility cannot be delegated. Disposal of Medicines
Medicines that have been prescribed for, and dispensed to, individual residents remain their property. If a resident leaves the care home their medication must be returned to them, or handed to their relative or carer, or returned to the community pharmacy with the permission of the resident or a relative. The action taken must be recorded in the resident's care record. At no time may one resident's prescribed medication be used for any other person. Refused medication should not be returned to the packaging but must be disposed of in the correct manner. Medication that is refused after it has been in the resident's mouth can be safely put into a yellow clinical waste bag. Medication no longer required must be returned to the community pharmacy with the following exceptions to be found in the Clinical Waste Management System:  Used Medicated dressings / patches to be folded in half and placed in yellow clinical  Fully emptied cream tubs/tubes to be disposed of in yellow clinical waste bag.  Empty inhalers or medicated aerosols to be placed in yellow clinical waste bag.  Other empty containers / bottles to be thoroughly rinsed out and placed in domestic  Equipment used to administer medication e.g. droppers, plastic spoons and measuring pots to be placed in yellow clinical waste bag.  Nursing homes should dispose of all medications in the secure medication disposal bins supplied by the pharmacy/ disposal company. All medications to be returned in this way must be checked, counted and entered into the pharmacy returns book and signed by 2 nominated persons.  The nominated person should advise the pharmacy when this is to be collected. All medication no longer required is to be returned to the community pharmacy or the approved company appointed. The Pharmacy Returns book to be completed in full:  Residents Name  Name of Medication  Quantity  Date  Initial of person making the entry  Signature of the second person checking Page 24 of 32
When returning medication to the pharmacy/approved company, the driver collecting the returns must sign and print their names. A duplicate copy is to be retained by the care home. Controlled drugs are not returned to the pharmacy. In a Residential Home, the pharmacist
should visit the care home to destroy them or take the medication back to the pharmacy for destruction. The Registered Manager must witness this and sign the controlled drugs book, recording that they have been returned or destroyed. The pharmacist must also sign the home's control ed drugs book. In a Nursing Home, controlled drug medication must be disposed of by placing it in a special
disposal container known as a doom kit. In addition to normal record keeping that must be completed when disposing of controlled drugs in this way, additional records must be made in the controlled drug register. The disposal container will then be collected as part of the waste drugs contract. Medication given to residents when leaving the care home must be counted, the amount recorded on the MAR sheet, initialled and dated. PRN medications in bottles or packs should be checked for expiry dates and sent back to the pharmacist when out of date. Any out of date items should be re-ordered from the individual resident's GP if stil required. Medication belonging to recently deceased residents must be kept for seven days before being returned to the pharmacist for disposal. If a resident has a syringe driver running at the time of death, this can be taken down by either the Nurse at the home, the GP at the time of death or by the district nurse, providing  The care home Registered Manager or Deputy Manager on duty acts as witness  The syringe driver is stopped by removing the battery  The syringe is removed from the device  The syringe is placed into a yellow rigid sharps bin complete with remaining contents and line. Do not discharge contents of the syringes.  A record is made on the monitoring chart, nursing notes, care record of the resident and in the care home's control ed drugs book if the medication was a control ed drug. The date, time, and amount of solution remaining in the syringe to be disposed of must be recorded, and signed by the GP or nurse witnessed by the care home Registered Manager or the deputy manager on duty.  Any unopened ampoules must be returned to the pharmacy for disposal after seven Medication Labels
Page 25 of 32
To enable nominated workers to administer medicines, there must be a printed label on every container with the following information, showing no discrepancies against the MAR  Resident's name  Date of dispensing  Name and strength of medicine  Dose and frequency of medicine, which must be the same as the current MAR chart If the label becomes detached from the container or is illegible a new label must be requested from the pharmacist. Nominated persons must never alter labels on dispensed medicines or, indeed, any
medicines. Any change in instructions from the GP must be recorded in the resident's care record. A new entry on the MAR chart must be made to reflect the change and it should be signed by two people – see verbal message procedure at 4.5. The community pharmacist must be contacted to communicate the new medicine dosage. A new prescription is to be obtained as soon as possible. 10.0 Record Keeping
10.0.1 All records must be completed fully, they must be legible and up to date and preferably produced using the computer rather than hand written records. All entries or alterations made by the Registered Manager/ Deputy/ Nominated person must be signed and dated by two people to confirm that the entry is correct. It is not permissible to erase any record with
correction fluid at any time. All documentation is to be retained by the care home. Used MAR charts should be retained for a minimum of 6 years. 10.0.2 The care home must keep a copy of the signed, original prescription and copies of medications returns documentation issued to pharmacists and maintained for audit trail. 10.0.3 An up to date record should be kept of care home staff authorised to administer medication. The record should document their name, status, signature and initials and be maintained All medication documentation should be kept in a secure place when not in use. 10.1 Records for controlled drugs:
10.1.1 Separate records of the receipt, administration and disposal of controlled drugs should be kept by all residential care homes.  Administration should be recorded on both the MAR chart and in the controlled drug  The controlled drug record book must be a bound book with numbered pages.  There should be a separate page for each controlled drug for each resident.  The balance remaining for each product should be included. This should be checked Page 26 of 32
against the amount in the pack or bottle at each administration.  It is the Registered Manager's responsibility to ensure that adequate stocks of CD books are available to staff. These can be obtained via supplying pharmacy. A CD Book must be available for each Treatment Room and Unit within the home. 10.1.2 Controlled drugs given by injection in residential homes are the responsibility of the community nurses. It is important to ensure that the residential home retains a record of all controlled drug administration, especially when the community nurse completes a record that is not left in the care home. The community nurse must make a record of this in the care home's Control ed Drugs register witnessed by a care home worker (trained to a minimum level 2 in medicines administration). The community nurse must write in the resident's care record details of the drug and dosage that has been administered. This must be cross referenced to the MAR chart. 11.0 Self-Administration for Residents
11.1 Nominated persons should always ask residents coming to live or stay at the care home if they wish to self-administer their own medicines. If residents express a preference to self- administer their medicines, a medication assessment is to be completed to identify where/if the resident requires support. A risk assessment must be carried out and If the risk assessment highlights concerns these must be discussed with the resident and identified risks care planned and risk managed. Registered Manager and their GP if necessary. (Appendices 8 & 9 It may be appropriate to put measures in place to minimise identified risks which still enable the resident to self-administer e.g. the care home stores the medication away from the resident, carers take the medication to the resident at the appropriate times and supervise them taking their medicines. If nominated persons have assisted the resident to administer medication, they must sign the MAR chart. 11.3 The resident should sign an agreement form to self-administer their own medication, to keep the medication safe in the lockable storage facility in their room and give permission that a duplicate key may be used by the nominated person, if required. Residents may wish to manage ordering of medication from their GP or pharmacy themselves and this is to be discussed and recorded. (Appendix 8). 11.4 The care home must provide secure storage in the resident's room. This can be a lock fitted to a drawer and does not need to be made of metal or even look like a medicines cupboard. 11.5 The level of support, and resulting responsibility of the care home worker, should be written in the medication care plan for each resident. This should also include continual monitoring of the resident to ensure capability to self-administer medicines. Monitoring how the resident manages to take their medicines, and regular review, form part of the resident's care. The Page 27 of 32
medicine records will help the review and monitoring process. The risk assessment should be reviewed at the monthly care plan review and a discussion with the resident regarding self-administration should take place. 11.6 All residents who self-administer should have a completed MAR chart indicating this. Hand/computer written entries made by the Registered Manager/ Deputy/ Nominated person are to be signed by the Registered Manager/ Deputy/ Nominated and another care home worker or resident. Refer to section 4.4 for MAR chart details. 11.7 Compliance aids e.g dosette boxes which may assist the resident to manage their medication should be made available. 12.0 Medication Errors
12.0.1 All MAR charts will be checked by the nominated person at the end of each shift for missing signatures and a medication handover completed. Missing signatures will be reported to the Registered Manager who will investigate further. 12.1 Mistakes in Administration
12.1.1 In the event of a resident receiving the wrong medication, an incident report form and a medication investigation form must be completed. (Appendix 10a & 10b). If there is any doubt about the person's wellbeing, dial 999 immediately. 12.1.2 The nominated person must:  Seek immediate medical advice  Inform the Registered Manager  Inform the resident and/or relative.  Monitor the resident in accordance with the instruction from the GP  Record full details of the incident, including time, medication given, action taken and full signature in the resident's medication care plan.  The Registered Manager will decide whether further action or investigation is required.  The Registered Manager will inform CQC and Care Manager if required.  The registered manager will raise a safeguarding alert.  A Reflective Practice Assessment Document will be completed by the individual responsible for the error. 12.1.3 Failure to follow any part of the medication administration procedure by any
nominated person is considered to be a medication error and will be investigated in
line with the procedures described in this document.
12.1.4 Each medication administration error made by a nominated person is to be assessed
for seriousness and the appropriate action will be taken by the Registered Manager.
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12.2 First Error
12.2.1 The nominated person responsible for the error must be invited to an investigatory meeting as part of the investigation to confirm the following (not exclusive): (See Appendices 11a,  How the incident occurred?  Was correct procedure followed?  What contributed to the error? 12.2.2 The Registered Manager, or Deputy Manager on duty in their absence, must investigate fully to prevent re-occurrence. 12.2.3 If this is the first error, the nominated person will be monitored, which includes:  Supervised sessions with the Registered Manager to check that the nominated person is administering medication according to the policy.  The nominated person must undertake a competency sheet which should be signed by the supervising person. 12.3 Second Error within a 6 Month Period
12.3.1 The nominated person responsible for the error must be invited to an investigatory meeting as part of the investigation to confirm the following (not exclusive): (See Appendices 11a,  How the incident occurred?  Was correct procedure followed?  What contributed to the error? 12.3.2 Following investigation through internal process, the registered manager must ensure that all recommendations from the investigation are carried out to ensure the safety of the residents. 12.4 Third Error within a 6 Month Period or a Serious Medication Error
12.4.1 The nominated person responsible for the error must be invited to an investigatory meeting as part of the investigation to confirm the following (not exclusive)(See Appendix 10a, 10b  How the incident occurred?  Was correct procedure followed?  What contributed to the error?  Immediate suspension from medication duties and a formal investigation must be  A two month period of re-training must take place, which must include participation in a medication administration training course  Supervision of administration of all medication by the Registered Manager, Deputy Manager or Designated Supervisor. Page 29 of 32
 A competency sheet and full assessment will be carried out at the end of this period.  Weekly spot checks for a further month by the Registered Manager or Deputy Manager on duty. 13.0 Holidays and short breaks
13.0.1 There wil be times that resident's wil be away from the home and they wil need to have their prescribed medication. It is the responsibility of the home to make sure that they have sufficient medication and that it is stored appropriately. Under no circumstances are you to secondary dispense medications (this is to dispense from the pre packed blister packs/medication bottles and put into another container for residents or their families to take home or to use that day)  If the resident is going out for the day it is best practice to give their medication before they leave in the morning  If they require medication only twice a day check with the GP that it is safe to administer the evening medication when they arrive back in the home.  If the resident is on analgesia and requires it throughout the day and the medications are in a bottle, count the medications with the resident/relative and get them to sign that amount of medication out and when they return sign the medication back into the home. They should also be given a copy of the MAR sheet so that they can sign it.  If the resident requires medication more often than twice a day and they are going to be out all day then again check this with the GP to see if this can be changed for that occasion and to have the medication when they return.  If this is not advisable from the GP then you must give the full pack/bottle of medications to the resident/relative and sign the medication out on the MAR sheet and sign it back in on their return. They will also need a copy of the MAR sheet for them to sign.  Make sure that this is risk assessed and care planned. 13.0.1 Procedure for short breaks of more than a day
 Staff should request from the Pharmacist the required amount of medication be dispensed in a separate container from the one used in the Home once they are made aware of the break  There should be an extra MAR sheet with this medication  The MAR sheet should be signed as self-medication for that period of leave.  The resident or their relative/next of kin should countersign the MARS sheet to agree they have received the medication from the Home.  If the resident has not taken any prescribed medication the reason should be sought from the resident and recorded onto the MARS sheet and also in their care plan. Page 30 of 32
 All this should be risk assessed and care planned and agreed with the GP. 14.0 Unidentified Medication
14.1 Medication found on the floor or elsewhere should be identified if possible, and an incident reporting form completed. If identified, an attempt should be made to ascertain which resident it belongs to and whether the resident has had that medication. If it is clear who the medication was intended for, the Registered Manager should decide on course of action and contact the resident's GP if deemed necessary. Missed doses of certain medicines can have a detrimental effect on resident's health and wel -being. 14.2 After the investigation has taken place, the medicine should be disposed of in the yellow
pharmacy medication bins. 15.0 Administering of Insulin, Injections, Enemas and Suppositories or Medicines
needing to be administered via a percutaneous endoscopic gastrostomy (PEG)
15.1 The administration of the above to residents in residential care homes always remains the responsibility of the GP or Community Nurse, unless this has been agreed with the GP and Community nursing team that Senior Carers, if trained are competent to carry out. The giving of enemas and suppositories is considered invasive therapy and should only be carried out by a registered practitioner; a Registered Nurse from the home may carry out this procedure. Should a specific nurse require guidance or support, then this should be discussed directly with the Home Manager. It is the responsibility of the Home Manager to source and action this support and guidance. 15.2 Oxygen may be prescribed for some residents. If this is the case, then:  Staff to follow company policy and procedure relating to oxygen, use and storage  All care home workers should be aware that oxygen is in use in the area.  Smoking or use of naked flame is prohibited in the area and notices stating "Compressed Gas: Oxygen": "No Smoking": "No Naked Lights", etc. should be used on the door of every room where oxygen cylinders are present, including the front door of the care home.  In the case of a fire, the Fire Service should be notified that oxygen cylinders are present on the premises and advised of their location.  Oxygen cylinders should be stored under cover, preferably inside, kept dry and clean and not subjected to extremes of heat or cold.  Oxygen cylinders should be stored upright and secure, ideally in a boxed in area.  Oxygen cylinders should not be stored near stocks of combustible materials or near sources of heat.  Full and empty oxygen cylinders should be stored separately. Full oxygen cylinders Page 31 of 32
should be used in strict rotation.  Oxygen cylinder valves should be closed when oxygen is not in use.  When the oxygen cylinder is empty the valve should be closed and the plastic cup refitted to the valve outlet to prevent moisture entering the oxygen cylinder.  f nominated persons are involved in the movement of oxygen cylinders, a manual handling risk assessment should be completed and the findings and recommendations communicated to all workers.  Refer to policy and procedure. 16.0 References
1. The Royal Pharmaceutical Society of Great Britain ‘The handling of medicines in Social 2. Care Quality Commission Outcome 9 – Management of Medicines 3. Commission for Social Care Inspection ‘Professional Advice: the administration of medicines in care homes'; April 2006 4. Commission for Social Care Inspection ‘Professional Advice: medicine administration records (MAR) in care homes and domiciliary care'; April 2006 5. Commission for Social Care Inspection ‘Professional Advice: Safe management of CD in care homes' January 2008 6. Commission for Social Care Inspection ‘Professional Advice: Training care workers to safely administer medicines in care homes' August 2007 Page 32 of 32


Pablo Oliveros Marmolejo † Gustavo Eastman Vélez Miembros Fundadores Marta Sandino de Oliveros Miembro de la Asamblea General Marcela Oliveros Sandino Presidente Asamblea General Consejera Corporativa Carlos Patricio Eastman Barona Presidente Fundación Universitaria del Área Andina Miembro Asamblea General

Csir-Forestry research institute of Ghana R SCIENTIFIC AND INDUSTRIAL R Annual Report 2011 R SCIENTIFIC AND INDUSTRIAL RE CSIR-FORESTRY RESEARCH INSTITUTE OF GHANA Annual Report 2011 CSIR-FORESTRY RESEARCH INSTITUTE OF GHANA © Copyright CSIR-FORIG 2012 For more information please contact:The DirectorCSIR-Forestry Research Institute of GhanaU.P.O Box 63Kumasi, Ghana.