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					Medication Policy and Procedural Guidance 1 June 10 , 2009 Final




Health and Adult Social Services
Policy Library




              MEDICATION POLICY AND GUIDANCE




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                                                                                                      Page 1 of 125
Medication Policy and Procedural Guidance 1 June 10 , 2009 Final




Category:                                 Registered Services,Domicillary and Day Services


Version Control:                          1


Date of Creation:                         March, 13, 2009


Last Modified:                            June 11th 2009


Review Date                               March 2010


EIA Assessment:                           TBD


Approving Body                            Directorate Management Team


Date of Approval                          31st July 2009 , for implementation


Contact Persons                           Sally-Anne Greenfield (SaGreenfield@northamptonshire.gov.uk)
                                          Jeanette Davies[jdavies@northamptonshire.gov.uk]


Either                                    OR

For public access online For staff access only (intranet)? (tick as appropriate)
(internet)



  No                                      Yes




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      CONTENTS

1         INTRODUCTION ................................................................................................................................ 11

2         RATIONALE....................................................................................................................................... 11

3         SCOPE ............................................................................................................................................... 11

4         CONTEXT .......................................................................................................................................... 11

    4.1   LEGAL FRAMEWORK                                                                                                                                    11

5         BASIC PRINCIPLES .......................................................................................................................... 12

6         CORE PROCEDURES ....................................................................................................................... 14

    6.1   MEDICATION INFORMATION ON ADMISSION TO A RESIDENTIAL ESTABLISHMENT                                                                                 14

          6.1.1        PLANNED ADMISSION ....................................................................................................... 14

          6.1.2        INITIAL REFERRAL ............................................................................................................ 14

          6.1.3        INFORMATION GATHERING ............................................................................................. 14

          6.1.4        HOSPITAL ADMISSION FORM .......................................................................................... 14

    6.2   EMERGENCY ADMISSION                                                                                                                                15

          6.2.1        CARE AUDIT TEAM ............................................................................................................ 15

          6.2.2        EMERGENCY ADMISSION FROM A HOSPITAL .............................................................. 15

    6.3   MEDICINES BROUGHT IN BY A SERVICE USER                                                                                                             15

    6.4   DETERMINING THE WISHES OF THE SERVICE USER                                                                                                         15

          6.4.1        THE SERVICES AVAILABLE .............................................................................................. 16

          6.4.2        SELF-ADMINISTRATION .................................................................................................... 16

          6.4.3        PARTIAL SELF-ADMINISTRATION .................................................................................... 16

          6.4.4        DISAGREEMENT ................................................................................................................ 16

          6.4.5        SERVICE USERS UNWILLING OR UNABLE TO SIGN FORM SS/159 ............................ 16

          6.4.6        CONFLICT OF WISHES BETWEEN STAFF AND SERVICE USER .................................. 16

          6.4.7        RESPONSIBILITY OF STAFF ............................................................................................. 17

          6.4.8        IDENTIFYING SERVICE USERS WHO SELF-ADMINISTER MEDICINES ....................... 17

          6.4.9        CHECKING THAT SERVICE USERS CAN SELF-ADMINISTER MEDICINES .................. 17

          6.4.10       SERVICE USERS NO LONGER ABLE TO SELF-ADMINISTER MEDICINES .................. 17



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   6.5    SUPPLY OF PRESCRIBED MEDICINES                                                                                                                18

          6.5.1        PRESCRIPTION FORMS .................................................................................................... 18

          6.5.2        REPEAT PRESCRIPTIONS ................................................................................................ 18

          6.5.3        QUANTITIES ....................................................................................................................... 18

          6.5.4        WHEN REQUIRED‟ (PRN) MEDICATION .......................................................................... 19

          6.5.5        ORDERING REPEAT MEDICINES ..................................................................................... 19

          6.5.6 RECORDS................................................................................................................................. 19

   6.6    OBTAINING DISPENSED MEDICINES                                                                                                                 20

          6.6.1        SINGLE PHARMACY .......................................................................................................... 20

          6.6.2        CONTAINERS FOR MEDICINES ADMINISTERED BY CARE STAFF: ............................. 20

          6.6.3  OCCASIONS WHEN THE PHARMACIST MAY DISPENSE MEDICINES IN TRADITIONAL
          MEDICINE CONTAINERS ................................................................................................................. 21

          6.6.4        CONTAINERS FOR SELF-ADMINISTERING SERVICE USERS ...................................... 21

          6.6.5        LABELLING ......................................................................................................................... 21

          6.6.6        CHANGES TO A DOSE ...................................................................................................... 22

          6.6.7        CLARITY OF DOSAGE INSTRUCTIONS ON LABELS ...................................................... 22

          6.6.8        RECEIPT OF MEDICINES INTO THE HOME. .................................................................. 23

          6.6.9        CHECKING PRINTED MAR CHARTS OR PREPARING PROFILES ................................ 23

          6.6.10       PATIENT INFORMATION LEAFLETS (PILS) ..................................................................... 23

   6.7    STORAGE OF MEDICINES                                                                                                                          24

          6.7.1        STORAGE OF MEDICINES FOR SELF-ADMINISTRATION) ............................................ 24

          6.7.2        STORAGE OF MEDICINES TO BE ADMINISTERED BY STAFF ..................................... 24

          6.7.3        SITE OF MEDICINE TROLLEYS AND CUPBOARDS ........................................................ 24

          6.7.4        CUSTODY AND STORAGE ................................................................................................ 25

          6.7.5        COLD STORAGE ................................................................................................................ 25

          6.7.6        STORAGE OF CONTROLLED DRUGS ............................................................................. 26

          6.7.7        QUANTITIES OF MEDICINES IN STOCK .......................................................................... 27

   6.8    ACCESS TO MEDICINES                                                                                                                           27




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           6.8.1      B5.1 STAFF AUTHORISED TO ADMINISTER MEDICINES .............................................. 27

           6.8.2      KEY SECURITY................................................................................................................... 28

     6.9   CONTROLLED DRUGS                                                                                                                            28

           6.9.1      DEFINITION......................................................................................................................... 28

           6.9.2      IDENTIFICATION OF CONTROLLED DRUGS .................................................................. 28

           6.9.3      SUPPLY AND RECEIPT OF CONTROLLED DRUGS........................................................ 29

     6.10 STORAGE OF CONTROLLED DRUGS                                                                                                                  29

     6.11 ADMINISTRATION OF CONTROLLED DRUGS                                                                                                           30

     6.12 DISPOSAL OF CONTROLLED DRUGS (## 9.5)                                                                                                        31

     6.13 RECORD KEEPING FOR CONTROLLED DRUGS                                                                                                          31

     6.14 CONTROLLED DRUGS REGISTER                                                                                                                    31

7          MEDICATION REVIEW BY A GP...................................................................................................... 32

     7.1   MATTERS TO BE CONSIDERED WHEN REVIEWING REPEAT PRESCRIPTIONS                                                                                32

           7.1.1      OPINIONS OF THE SERVICE USER ................................................................................. 32

           7.1.2      OPINIONS OF STAFF ......................................................................................................... 32

           7.1.3      POINTS TO RAISE WITH THE GP/COMMUNITY PHARMACIST: .................................... 32

     7.2   FREQUENCY OF REVIEW                                                                                                                         33

     7.3   MEDICATION REQUIRING REGULAR MONITORING                                                                                                     33

     7.4   PRESENCE OF A MEMBER OF STAFF DURING DOCTORS‟ CONSULTATIONS                                                                                 33

8          PRESCRIPTIONS LEFT BY A VISITING DOCTOR ......................................................................... 34

     8.1   OUTSIDE OF NORMAL PHARMACY HOURS                                                                                                            34

9          EMERGENCY SUPPLIES OF PRESCRIPTIONS ONLY MEDICINES............................................. 34

10         MEDICINES FOR EMERGENCY USE .............................................................................................. 35

11         ADMINISTRATION OF MEDICINES ................................................................................................. 35

     11.1 ADMINISTRATION BY THE SERVICE USER                                                                                                           35

     11.2 ADMINISTRATION BY STAFF                                                                                                                      35

     11.3 TIMES OF ADMINISTRATION OF DOSES                                                                                                             35




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     11.4 IDENTIFICATION OF SERVICE USERS                                                                                                       36

     11.5 DIRECT ADMINISTRATION                                                                                                                 36

     11.6 RECORDS                                                                                                                               36

     11.7 PROCEDURE FOR THE ADMINISTRATION OF MEDICINES BY CARE STAFF                                                                           37

     11.8 REFUSAL OF MEDICINES                                                                                                                  39

     11.9 SPOILED DOSES                                                                                                                         40

     11.10 TIMES WHEN MEDICINE MAY BE GIVEN IN FOOD                                                                                             40

     11.11 ALTERNATIVE REMEDIES                                                                                                                 40

     11.12 MEDICINAL OXYGEN                                                                                                                     41

     11.13 ERRORS IN ADMINISTERING A DOSE                                                                                                       41

     11.14 NEAR-MISS INCIDENT REPORTING                                                                                                         42

     11.15 SUSPECTED ADVERSE DRUG REACTIONS (ADRS)                                                                                              42

12        ADMINISTRATION OF MEDICINES AWAY FROM THE CARE HOME .......................................... 42

     12.1 ATTENDANCE AT DAY CARE CENTRES                                                                                                        42

     12.2 A SHORT UN-PLANNED ABSENCE (E.G. LUNCH OUT WITH A RELATIVE).                                                                          43

     12.3 GROUP DAY TRIPS OUT FROM THE HOME                                                                                                     43

     12.4 HOLIDAYS AWAY FROM THE HOME                                                                                                           43

13        DISPOSAL OF MEDICINES .............................................................................................................. 44

     13.1 GENERAL INFORMATION                                                                                                                   44

     13.2 MEDICINES REMOVED FROM THE HOME                                                                                                       44

     13.3 CONTROLLED DRUGS                                                                                                                      45

14        HOUSEHOLD REMEDIES ................................................................................................................. 45

     14.1 GENERAL INFORMATION                                                                                                                   45

15        MEDICINES PURCHASED BY OR ON BEHALF OF SERVICE USERS......................................... 46

16        DAY CARE SERVICES ..................................................................................................................... 46

     16.1 INTRODUCTION                                                                                                                          46

     16.2 THE INITIAL ASSESSMENT                                                                                                                46



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     16.3 GATHERING INFORMATION.                                                                                                                        47

17         CHANGES TO MEDICATION............................................................................................................ 47

18         SELF-ADMINISTRATION AND COMPLIANCE AIDS ...................................................................... 47

     18.1 SURRENDERING MEDICINES TO STAFF                                                                                                               48

     18.2 COUNSELLING ON ADMISSION                                                                                                                      48

     18.3 EVALUATING RISK TO THE SERVICE USER                                                                                                           48

     18.4 EVALUATING RISK TO OTHER SERVICE USERS                                                                                                        48

     18.5 INABILITY TO SAFELY SELF-ADMINISTER MEDICINES                                                                                                 49

19         ADMINISTRATION OF MEDICINES BY STAFF .............................................................................. 49

20         PROVISION OF OUTREACH SERVICES ......................................................................................... 50

21    MEDICATION DOCUMENTS AND PROCEDURES FOR ADMINISTERING MEDICINES (ALL
ADULT ESTABLISHMENTS) ......................................................................................................................... 50

     21.1 THE PURPOSE OF MEDICATION RECORDING DOCUMENTS                                                                                                 50

     21.2 GUIDELINES FOR COMPLETING MEDICATION RECORDING DOCUMENTS                                                                                      51

           21.2.1      Printed MAR charts supplied by the pharmacy ................................................................... 51

           21.2.2      Hand written recording documents. ..................................................................................... 51

     21.3 PROCEDURE FOR COMPLETING HAND WRITTEN DOCUMENTS FOR EACH SERVICE
     USER                                                               52

           21.3.1      Raise a medication PROFILE CARD and a RECORDING CARD. ..................................... 52

           21.3.2      Completing a Profile Card .................................................................................................... 52

           21.3.3      Completing the Recording Card .......................................................................................... 52

           21.3.4      Records of Medicines Received and Destroyed .................................................................. 53

           21.3.5      Controlled Drugs .................................................................................................................. 53

22         INFORMATION AND TRAINING ....................................................................................................... 54

     22.1 GENERAL INFORMATION                                                                                                                           54

     22.2 INVOLVEMENT OF COMMUNITY PHARMACISTS                                                                                                          54

           22.2.1      Advice on Individual Medicines............................................................................................ 55

           22.2.2      Advice on Medication Procedures ....................................................................................... 55




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          22.2.3       Medicines Information .......................................................................................................... 55

23        WEBSITE ADDRESS FOR THIS POLICY ........................................................................................ 56

24        NOTES ............................................................................................................................................... 56

25        ACKNOWLEDGEMENTS .................................................................................................................. 56

26        GLOSSARY ....................................................................................................................................... 57

27        APPENDICES .................................................................................................................................... 59

28        Appendix 1 ........................................................................................................................................ 60

     28.1 National Minimum Standards, Standard 9, Medication Outcome                                                                                         60

29        Appendix 2 ........................................................................................................................................ 62

     29.1 Contents Of The Royal Pharmaceutical Society Document - „„The Administration And Control Of
     Medicines In Care Homes And Children‟s Services‟                                                 62

30        Appendix 3 ........................................................................................................................................ 64

     30.1 Model Form Of Agreement Between The Team Manager And The Community Pharmacist                                                                      64

31        Appendix 4 ........................................................................................................................................ 66

     31.1 Suggested System For Examining And Identifying Medicines Brought Into An Establishment By A
     Service User                                                                                     66

32        Appendix 5 ........................................................................................................................................ 68

     32.1 Key Points On Consent: The Law In England                                                                                                          68

33        Appendix 6 ........................................................................................................................................ 70

     33.1 Risk Assessment Form For Service Users Wishing To Self-Administer Medicines                                                                        70

34        Appendix 7 ........................................................................................................................................ 74

     34.1 Declaration Of Self-Custody Of Medicines (Form Ss/159)                                                                                             74

35        Appendix 8 ........................................................................................................................................ 75

     35.1 Service Users Unable To Make Declaration Of Self-Custody Or Medicines (Form Ss/160)                                                                75

36        Appendix 9 ........................................................................................................................................ 77

     36.1 Service Users Requiring Adminstration Of Medicines In Food Or Drink Because Of Problems With
     Swallowing Tablets Or Capsules                                                                    77

37        Appendix 10 ...................................................................................................................................... 79




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     37.1 Service Users Requiring Administration Of Medicines In Food Or Drink Because Of An Impaired
     State Of Mind                                                                                    79

38        Appendix 11 ...................................................................................................................................... 81

     38.1 Medication Profile Card And Recording Card                                                                                                      81

39        Appendix 12 ...................................................................................................................................... 83

     39.1 Medication Unsuitable For Inclusion In A Monitored Dossage System                                                                               83

40        Appendix 13 ...................................................................................................................................... 85

     40.1 Maximum/Minimum Fridge Temperature Chart                                                                                                        85

41        Appendix 14 ...................................................................................................................................... 87

     41.1 Schedule 2 Controlled Drugs: Generic And Propriety Names                                                                                        87

42        Appendix 15 ...................................................................................................................................... 89

     42.1 Guidelines For Use Of The Controlled Drugs Register In Residential Homes                                                                        89

43        Appendix 16 ...................................................................................................................................... 90

     43.1 Model Letter To Pharmacies Requesting Identification Of Fridge Lines And Controlled Drugs                                                       90

44        Appendix 17 ...................................................................................................................................... 91

     44.1 Model Letter To Pharmacies Requesting Labels Of Both Containers And Packaging (Boxes) Where
     Appropriate                                                                                    91

45        Appendix 18 ...................................................................................................................................... 92

     45.1 Suggested Letter To Carers About Medicines Information And The Proper Packing Of Medicines For
     Day Care Service                                                                                 92

46        Appendix 18a .................................................................................................................................... 93

     46.1 Suggested Letter To Carers About Medicines Information And The Proper Packaging Of Medicines
     For Short Term Care Service Users                                                               93

47        Appendix 19 ...................................................................................................................................... 94

     47.1 Service User Medical Administration Record (Mar)                                                                                                94

48        Appendix 20 ...................................................................................................................................... 95

     48.1 Example Of A Hospital Admission Forms :Copy In Green Paper                                                                                      95

49        Appendix 21 ...................................................................................................................................... 96

     49.1 Northamptonshire County Council Adults Household Remedies Policy                                                                                96



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50        Appendix 22 ...................................................................................................................................... 98

     50.1 List Of Household Remedies                                                                                                                      98

51        Appendix 23 ...................................................................................................................................... 99

     51.1 Flow Charts For Household Remedies                                                                                                              99

52        Appendix 24 .................................................................................................................................... 109

     52.1 Northamptonshire County Council, Medication Error Policy                                                                                      109

53        Appendix 25 .................................................................................................................................... 111

     53.1 Medication Error/Near Miss Incident Report Form                                                                                               111

54        Appendix 26 .................................................................................................................................... 117

     54.1 Medicine And Alcolhol: Combination To Be Avoided                                                                                              117

55        Appendix 27 .................................................................................................................................... 118

     55.1 Warfin: Things To Be Aware Of                                                                                                                 118

56        Appendix 28 .................................................................................................................................... 119

     56.1 Monoamine Oxidase Inhibitors: Foods To Be Avoided                                                                                             119

57        Appendix 29 .................................................................................................................................... 120

     57.1 Medicines Which Interact With Grapefruit                                                                                                      120

58        Appendix 30 .................................................................................................................................... 121

     58.1 Fax Back Forms For Gp‟s                                                                                                                       121

59        Appendix 31 .................................................................................................................................... 125

     59.1 Induction Tool Kit                                                                                                                            125




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1     INTRODUCTION

This policy and procedural manual provides guidance aimed at helping staff to care for service
users‟ needs related to the use of medicines, oxygen and appliances. It describes the
procedures involved in medication - requesting repeat prescriptions, storage, administration
and recording, as well as procedures to be followed if losses and errors occur. The correct and
safe administration of medicines involves Social Care staff, doctors, pharmacists and nurses.
It especially requires co-ordination and co-operation between all staff who work in the field of
health and H.A.S.S.

2     RATIONALE

The correct and safe administration of medicines involves Social Care staff, doctors,
pharmacists and nurses. It especially requires co-ordination and co-operation between all staff
who work in the field of health and H.A.S.S.

3     SCOPE

      The Code applies to all Social Care , residential and day service establishments where the
      welfare of service users is the direct responsibility of the Social Care Sector with an aim to
      encourage the participation of Independent Sector employees.

4     CONTEXT

4.1     LEGAL FRAMEWORK

Medicines prescribed for service users become their property as soon as they are dispensed.
Nevertheless, responsibility for safe custody, administration and disposal of medicines within
the establishment rests with the Social Care or the Independent Sector Home manager,
whether the service user is self-administering or not.

Within a residential care setting, the administration of medicine must be performed in
conjunction with the policy of the establishment. In the case of Northamptonshire Older Adults
establishments, this Medicines Code constitutes the policy. This details the requirements for
the administration and control of medicines within care homes. This code conforms to the
National Minimum Standards for Care Homes for Older People.

Standard 9, para 9.11 of the National Minimum Standards for Care Homes for Older People
states that there is a requirement that medicines be retained for a period of 7 days upon the
death of a service user in case there is a coroner‟s inquest.

The Health and Safety at Work Act 1974 imposes a general duty on employers to ensure, so
far as is reasonably practicable, the health, safety and welfare of employees and others
including service users.




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With respect to the administration, storage and disposal of medicines, the requirements of the
Medicines Act 1968, Misuse of Drugs Act 1971 and its subsequent regulations are all
observed within this code.

Summary of legislation underpinning policy and guidance:

       The Medicines Act 1968 (plus amendments)
       The Misuse of Drugs Act 1971 (Controlled Drugs)
       The Misuse of Drugs Act (Safe Custody) Regulations 1973
       The Health and Safety at Work Act 1974
       The Access to Health Records Act 1990
       The Data Protection Act 1998
       COSHH Regulations 1999 (concerns substances hazardous to health)
       The Care Standards Act 2000 (receipt, storage and administration of medicines)
       The Health and Social Care Act 2001
       The Hazardous Waste Regulations 2005
       The Health Act 2006
As a result of this legislation, new regulations apply that have given rise to:-
       The National Care Standards Commission for England (NCSC)
       National Minimum Standards (NMS) for England and Wales.
       The Mental Capacity Act 2005
       The Deprivation of Human Liberty Act April 2009.


5     BASIC PRINCIPLES


The following ten principles are a summary of the major points that are expanded elsewhere.
They are intended to produce the safest and simplest process achievable, thus ensuring that
the right medicine is received by the right service user in the right dosage at the right time.

     1. Rights and dignity of service users

All activities related to medicines should be conducted in such a way as to maintain the rights of
service users and to preserve their dignity and control of their own lives. Particular attention should
be given to taking account of service users‟ beliefs, wishes and cultural background. The expertise
and experience of staff is utilised in order to minimise any undesirable features of an institutional
approach to administering service users‟ medicines.

     2. Risk assessment to establish ability to self-medicate

Adult service users must be regarded as responsible for their own medicines unless a formally
recorded decision, which includes a risk assessment (see Appendix 6) and consultation with the
service user and possible family members, has been made to the contrary.

     3. Maximum quantity of medication to be ordered

 No more than twenty-eight days‟ supply of medicines, including those on repeat prescriptions,
should be requested for an individual at any one time.


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     4. Review of long-term medication.

All medicines prescribed on a long term basis should be regularly reviewed at reasonable intervals
by the prescribing General Medical Practitioner (GP). It is in the interests of the service user that
Team Managers should take steps to encourage the review of these prescriptions. The assistance
of the local community pharmacist should, if necessary, be sought with respect to liaising with GPs
to initiate the review of prescriptions. (Section B7)

     5. No sharing of prescribed medicines.

Medicines prescribed for one person must not be used for any other person.

     6. Only use medicines from original dispensing containers.

Administration of medicines to service users by staff must only be carried out from the original
container in which the medicine was dispensed.

     7. Record on administration

Every dose administered to a service user by staff must be individually recorded at the time it is
given. If the dose is not taken by the service user, this must be recorded and the reason why the
dose has not been taken should be noted, using an appropriate code.

     8. Return unwanted medicines to the pharmacy

Medicines must not be retained in the home when no longer required.

     9. Household Remedies

A small range of Household Remedies may be kept for the treatment of minor self-limiting ailments
which would not normally require consultation with a doctor. Homely remedies must not be used
for more than three days without reference to the service user‟s GP. Detailed guidance on the use
of household remedies can be found in Appendices 21, 22 & 23.

     10. Encouraging Independence

 Service users should be encouraged to self-administer and maintain independence. This can
include service users who self-medicate from original dispensing packs or from individual
compliance aids. Where this is not possible a monitored dosage system is appropriate, if space
allows.




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6     CORE PROCEDURES

6.1     MEDICATION  INFORMATION                                 ON       ADMISSION                TO   A   RESIDENTIAL
        ESTABLISHMENT



      6.1.1 PLANNED ADMISSION

a) Long-term Care
b) Short term/respite care
c) Day Care

The following information is common to all three of the above categories.

      6.1.2      INITIAL REFERRAL

Information about medicines for planned admissions should be gathered during the assessment
processes when a service user first presents. Information is entered onto Framework by the
assessment officer and sent to the establishment identified as appropriate for the service user
either via the computer or in hard copy.


      6.1.3      INFORMATION GATHERING

The care establishment receives the referral from the assessing officer[could be Care Manager]
and this is followed by a „Provider‟s Assessment to determine whether the home can appropriately
meet the person‟s needs and to develop a Personal Care Plan (it is not to repeat the „needs‟
assessment already completed, unless there are any gaps). NB the Provider‟s Assessment can be
undertaken in the residential home or other settings as deemed appropriate. The visit should be
made before the service user is admitted to (or attends in the case of day care) the establishment.
The visiting manager may take written advice and information about medicines for the service user
and or carer and will gather necessary information at the visit, some of which will be a list of the
medicines which the service user takes and the times when taken. The manager will decide on the
level of help which the service user will need.

Confirmation of the medical information will then be requested from the service user‟s GP, (with the
service user‟s consent), The GP may make a charge for supplying this information .see appendix
30.

For service users attending short break services, medicines‟ information must be taken each time
they are admitted to the establishment in order to ensure that any changes in medication from
one stay to another are accounted for.

      6.1.4 HOSPITAL ADMISSION FORM

It is recommended that a hospital admission form should be completed as soon as possible for
every service user (example at Appendix 20). This should be updated when necessary to reflect



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any changes in medication and kept on file so that, in the event of the service user being admitted
to hospital, the information is ready to give to the paramedics along with the service user‟s
medication.

6.2     EMERGENCY ADMISSION


      6.2.1 CARE AUDIT TEAM

Emergency admissions of service users, often out of hours, direct from their own home are usually
handled by the Care Management Out of Hours team. A representative from the team will have
assessed the situation and gathered as much information as possible. The Team Manager (or
night staff) on duty is then contacted to request accommodation. If accommodation is available,
the Team Manager should be provided with information gathered by the Duty Team. This should
include information about medicines. Contact should however be made as soon as possible with
the service user‟s GP to confirm this information and completed by the GP. see appendix 30

      6.2.2 EMERGENCY ADMISSION FROM A HOSPITAL

Service users admitted from a hospital (for example after a fall) will have been assessed at the
hospital and will be sent out with medication, usually a seven day supply. The GP should be
contacted as soon as possible and sent ,see appendix 30 together with information relevant to the
hospital admission and discharge.

6.3     MEDICINES BROUGHT IN BY A SERVICE USER

There will be occasions when a service user arrives at an establishment with a large quantity of
medicines, often in a carrier bag. It will be necessary to identify which medicines are needed by the
service user. A system for examining and identifying the medicines is included at Appendix 4. This
may seem to be very long and involved but it has been produced to cover the worst scenario.
Medicines brought into a home must be recorded as described in Section B3.3.8.

When the medicines have been sorted out and the regular medicines identified, the information
about them should be entered onto a MAR or Profile and Recording Card at handover with the
manager coming on duty. Both managers should sign or initial the MAR or card to confirm that this
is the correct medication and dose.

6.4     DETERMINING THE WISHES OF THE SERVICE USER

When service users first come to live in a residential home, it should be assumed that they may
wish to be responsible for the custody and administration of their own medicines. These wishes
should be ascertained before, or very soon after, they enter residence. There are clear advantages
for service users in exercising this choice in terms of preserving and enhancing independence and
quality of life and in preparing for a return home. However, there will be occasions when new
service users have not been used to taking charge of their own medicines or are considered
incapable of doing so. The process for determining the wishes of the service user should be
conducted as described below.


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      6.4.1 THE SERVICES AVAILABLE

The service user should be informed of the service that the staff will provide in terms of safety,
central custody and administration of medicines, and of the advantages and responsibilities of
retaining their own medicines.

      6.4.2 SELF-ADMINISTRATION

Service users who wish to retain responsibility for their own medicines, should be risk assessed in
order to determine their ability to do so. Risk assessments should be carried out at six monthly
intervals (or sooner if, in the opinion of the care home staff, their ability to self-medicate becomes
questionable). A suitable form to use for risk assessment is available at Appendix 6. Evidence of
the risk assessment should be kept with the service user‟s care plan. After the assessment, service
users who will retain responsibility for their own medicines should be asked to complete and sign a
Form SS/159; Declaration of Self-Custody of Medicines (see Appendix 7). The service user should
be given a copy of the completed form. The original copy should be filed with the service user‟s
personal records.

      6.4.3 PARTIAL SELF-ADMINISTRATION

If a service user only wishes to take partial responsibility – that is, to self-administer some but not
all medicines - this should be noted in the space for “other options” on Form SS/159. The service
user‟s MAR should indicate which medicines are self-administered and which are administered by
staff.

      6.4.4 DISAGREEMENT

If a service user or relative or carer expresses disagreement with a decision recorded on Form
SS/159, then the Responsible Person in Charge should complete Form SS/160 (Service User
considered unable to exercise choice of handling medicines - Appendix 8). This is optional for day
care service users - see Section C, 1.1.5. If used, Form SS/160 should be placed with the service
user‟s personal records.

      6.4.5 SERVICE USERS UNWILLING OR UNABLE TO SIGN FORM SS/159

If a service user is unwilling or unable to sign Form SS/159 (Appendix 7), their choice should,
nevertheless, be recorded on that form by the Responsible Person in Charge and witnessed by a
third party.

      6.4.6      CONFLICT OF WISHES BETW EEN STAFF AND SERVICE USER

It is recognised that there may be situations when a service user wishes to control their own
medicines but, for reasons of learning disability or physical disability, is unable to fully do so. Every
effort should be made including the use of compliance aids to accommodate the needs of such
service users if possible. For example, service users may wish to take custody of their own



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medicines but be unable, because of physical disablement, to administer them without help. Under
these circumstances it may be appropriate for staff to assist the service user by physically helping
them with the administration of medicines.

      6.4.7 RESPONSIBILITY OF STAFF

The responsibility of staff does not finish with the completion of Form SS/159 or Form SS/160. A
sensitive balance has to be found between the service user‟s freedom of choice and the need to
ensure that this choice does not constitute undue risk to themselves or to others in the home. The
responsibility for continual assessment of this risk is a difficult professional issue and rests
ultimately with the Team Manager.

      6.4.8      IDENTIFYING SERVICE USERS W HO SELF-ADMINISTER MEDICINES

Service users who administer their own medicines should be clearly identified on the care plan by
endorsing the words “self-administered” on the Care Plan and on the Medication Administration
Record (MAR) or the Profile and Recording Card (whichever is used).

For service users who partially self-administer their medication, the MAR should show clearly
which medicines are administered by staff and those administered by the service user, eg inhalers.

Service users who have custody of their own medicines but who require assistance in
administering some of them should be clearly identified on the care plan and on the medication
records or MAR.

      6.4.9 CHECKING THAT SERVICE USERS CAN SELF-ADMINISTER MEDICINES

Staff should make ongoing checks and carry out six monthly risk assessments to ensure that
service users are managing the administration of their medicines successfully and are not placing
themselves or others at risk. The assessment should be recorded on the Administer Medicines,
Appendix 6. The physical and mental condition of the service user should be taken into
account when assessing the situation. Staff undertaking risk assessments are advised to seek
the opinions of other colleagues (eg the line manager or identified worker) and health care
professionals, such as the GP, community pharmacist or district nurse, to assist in making the
correct decision. If a service user exercises the right to administer their own medicines, the
community pharmacist should be informed so that the medicine can be dispensed in an
appropriate container.

      6.4.10 SERVICE USERS NO LONGER ABLE TO SELF-ADMINISTER MEDICINES

If a service user who has exercised choice of custody and administration of their own
medicines is considered no longer capable of doing so, the matter should be carefully
discussed with the individual and a written agreement to change the responsibility for
medication should be obtained. Where agreement cannot be obtained the matter should be




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discussed with the line manager before a decision is made to set aside the service user‟s
preferred choice. (Appendix 6 and Appendix 8 Form SS/160).

6.5     SUPPLY OF PRESCRIBED MEDICINES


      6.5.1 PRESCRIPTION FORMS

The majority of medicines received into homes are those that have been prescribed for a
service user by their GP on an NHS prescription form FP.10. Alternatively, medicines may be
prescribed on a private prescription written by a qualified medical practitioner. NB: Private
prescriptions involve the payment of a private prescription fee by the service user. There may
be occasions when, due to error or unforeseen circumstances, the GP has not furnished the
staff with a prescription for medicines that are required for a service user. In these
circumstances the onus is upon the home staff to contact the GP and make a request for a
prescription. However, there may also be occasions when it is more appropriate for the
community pharmacist to contact the GP directly to discuss the prescription or to obtain
verification prior to receiving prescription form FP.10. A doctor may provide a pharmacist with
a verbal message of the contents of a prescription, provided that a prescription form is
supplied to the pharmacist within 72 hours.

NB: The latter procedure is not permitted for Controlled Drugs.

      6.5.2 REPEAT PRESCRIPTIONS

Many service users are prescribed medicines on a long term basis, but this should not be
taken to mean that such medicines can or should be taken „ad infinitum‟. Any uncertainty
about whether a prescription can be repeated should be discussed with the service user‟s GP.
The community pharmacist may also give additional advice about repeat prescriptions and,
when appropriate, could discuss such matters with the GP on behalf of the home staff/service
user. .

      6.5.3 QUANTITIES

Staff may, on behalf of service users, make requests to GPs for further supplies of medicines
on a 28 day basis. Quantities of medicines requested must not exceed a 28 days supply
because of the risk of excessive stocks accumulating in the home. This can result in
overloading of the available storage space and possible confusion when staff come to
administer medicines to service users. Excessive quantities of medicines also lead to a waste
of resources when medicines are discontinued or changed or if a service user dies. This
advice should also be given to service users who have custody of their own medicines and
who may order their own medicines.




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      6.5.4 WHEN REQUIRED‟ (PRN) MEDICATION

If a patient is taking „When Required‟ (PRN) Medication, it can be carried forward at the end of
the month to the next month and does not have to be discarded providing:

          The medication is still being prescribed by the doctor at the same dose and frequency

          The medication is in an original pack with an expiry date so it can be checked that the
          medication is still in date. Examples include paracetamol tablets, salbutamol inhaler,
          senna tablets etc.

          The Care Home will have to indicate the quantity of medication brought forward to
          enable a stock check to be carried out.

          Careful consideration needs to given to the administration of “PRN”” medication as to
          whether written guidance is required via the GP.or relevant Healthcare professional eg
          for the treatment of Epilepsy , for customers with long term pain management regimes
          and also to support the control of anxiety.


                  Please note that the Care home will also have to consider how it handles
                  repeat prescriptions for „When Required‟ medicines because if the stock
                  of medication is carried forward, they will need to ensure that this
                  medication is not requested along with the other repeat medicines, to
                  ensure that the medication is not prescribed and not dispensed. This will
                  enable a cost effective approach and reduce the wastage and costs of
                  medicines.

If „when required‟ medicines are carried over, the quantities carried over must be noted on the
new MAR chart to allow an audit trail of medicines.

      6.5.5 ORDERING REPEAT MEDICINES

The manager/designated person in the establishment should initiate the order for new
prescriptions and not delegate this task to the supplying pharmacy. It is considered essential
for the manager/designated person to see the prescription forms to check them against the
items that were ordered before they are submitted to the pharmacy. Prescription forms are
signed by the GP, the signature is the authority to supply and to administer the medicine.

6.5.6 RECORDS

Requests for repeat medication will usually be made using the surgery‟s own repeat
medication request slips or the pharmacy produced copy of the MAR. Only occasionally will
requests be made verbally. A record must be made of each request and must specify the
service user‟s name, the medicine name, strength (if appropriate) the frequency of
administration and the requested quantity (28 days supply). The designated officer must


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ensure that a permanent copy of the medicines requested is available in the home. (A record
must also be made of the date and quantity of each medicine received to ensure that those
medicines required are, in fact, received as ordered.)

6.6     OBTAINING DISPENSED MEDICINES



      6.6.1 SINGLE PHARMACY

It is desirable that each home should deal with one local community pharmacy. This is
important because it will enable the pharmacist to develop an advisory role on all aspects of
medicines and medication procedures affecting service users in the home. Service users have
a right to take their own prescription to a pharmacy of their choice for dispensing. If they are
capable they should be encouraged to do so. However, in most instances it is anticipated that
staff will obtain service user‟s medicines for them.


      6.6.2 CONTAINERS FOR MEDICINES ADMINISTERED BY CARE STAFF:

The pharmacist will make an assessment of a suitable container for each medicine. Any
queries should be taken up with the pharmacist.

It is quite acceptable for medicines to be dispensed in traditional bottles and packs but if this
system is used the medicines for each service user should be kept together (in drawers or
boxes) in the medicines trolley.

Most medicines dispensed for Northants County Council Social Care Residential Homes are
dispensed into a Monitored Dosage System (MDS) of one kind or another and staff in the
homes will be familiar with these. If a new MDS is introduced, the supplying pharmacist will
demonstrate the system to managers and staff.

Not all medicines are suitable for inclusion in an MDS as explained below. Medicines to be
administered „when required‟ should not be packaged into MDS as their expiry date will be
affected by the repackaging and, while they will be quite stable for several weeks, tablets or
capsules should not be left in an MDS for months at a time. It is imperative that all medicines
packed into an MDS can be identified. Most of the MDS used in Northamptonshire Social Care
Residential Homes are of the type in which only one type of tablet is put into each pocket, thus
identification is by referral to the label on the card containing the tablets or capsules. In some
systems, however, tablets and capsules may be placed together in a pocket to be given at a
particular dose time. This type of system has time saving advantages, however, tablets and
capsules which are of such a similar appearance that they cannot be easily identified should
not be put together. Labelling should enable individual medicines to be identified.




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      6.6.3 OCCASIONS WHEN THE PHARMACIST MAY DISPENSE MEDICINES IN
            TRADITIONAL MEDICINE CONTAINERS

     a. For service users receiving short-term care (two weeks maximum stay).

     b. Newly admitted service users may use up their own supplies of medication prior to
        changing to the Monitored Dosage System (MDS) at the next renewal date.

     c. Other exceptions such as large dosage forms and liquids etc, which are inappropriate
        to be placed within a Monitored Dosage System.

     d. Short courses of antibiotics.

     e. Certain Medicines are unsuitable for inclusion in an MDS

          See Appendix 12 for a list of such medicines which was issued by the Boots Company
          in 2001, this is a helpful guide. Since that time, however, the number of generic drug
          manufacturers has increased and it has become very difficult to access stability
          information for all the tablets used. Your community pharmacist will make a judgment at
          the time of dispensing about whether to put tablets into an MDS or not.

      6.6.4 CONTAINERS FOR SELF-ADMINISTERING SERVICE USERS

Medicines dispensed for service users who administer their own medication may be dispensed
in standard containers, ie original packs, or glass or plastic bottles which will have child-
resistant closures. If a service user has difficulty removing such closures, ordinary caps can be
supplied if the pharmacy is notified of the problem. Alternatively, service users who administer
their own medicines may require a compliance aid (NB not the kind of MDS used by home
staff). These should preferably be filled at a pharmacy, though please remember that not all
pharmacies offer this service. Some service users may be able to fill their own. Alternatively,
family members or a friend may fill a compliance aid for the service user on a weekly visit. The
community pharmacist may be willing to give assistance by discussing times of doses with the
service user or their family or even by providing a plan of the layout of the tablets or capsules
in the compliance aid, however, such a service is not remunerated and should not be assumed
upon.


                  Under no circumstance should residential home staff put medication into
                  compliance aids for use by service users who administer their own
                  medicines.

      6.6.5 LABELLING

Pharmacists have a legal and ethical obligation to label all dispensed medicines to a standard
laid down by the Royal Pharmaceutical Society.



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Every label should carry the following information:-

     a.   The name of the service user
     b.   The name and strength of the medicine
     c.   The quantity of the medicine supplied
     d.   The precise dose to be administered, (clarify if not clear)
     e.   Any mandatory warnings, (eg take with or after food)
     f.   The date the medicine was dispensed

Labels must not be altered in any way by home staff unless instructed to do so by a GP.


      6.6.6 CHANGES TO A DOSE

Occasionally, a GP may issue a verbal order to change a medication or dose. A written
protocol must be set up in each home for the recording of verbal messages by designated
staff, whether from the GP in person or by telephone. For telephone messages, written
confirmation should be requested by fax if possible.[Appendix 32] If possible a visiting GP
should be asked to sign or initial a note of the change. Details of the change should be added
to the MAR, or other recording chart, in such a way that the change is obvious to anyone who
may be administering medicines after the change.

Some pharmacies may issue a new or an additional MAR chart when they know that there has
been a medication change. It is important that the original MAR chart is marked to indicate
this.
The name of the GP authorising the change and the designated member of staff making the
change must be recorded, the member of staff must sign and date the information.
NB Only changes to medication can be authorised by a GP verbally. New medication with a
Prescription Only Medicine (POM) cannot be initiated in this way.

      6.6.7 CLARITY OF DOSAGE INSTRUCTIONS ON LABELS

Instructions on labels should be clear and unambiguous, „as before‟ or „as directed‟ are
unacceptable and should be queried with the GP, pharmacist or dispensing doctor for
clarification. Instructions such as „when required‟ should be expanded with a reason, eg „when
required for pain‟. The dose range and a maximum dose should be stated. Complicated
dosage instructions which would not fit onto a label should be discussed with the GP, clear
instructions should be put onto the service user‟s care plan with reference to this on the MAR.

Labels on products for application to the skin should indicate the areas of the body to which it
should be applied. This is particularly important if a service user who has several different
creams, ointments or lotions, many of which may be potent.

A container must be returned immediately for re-labelling if the label is detached.




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      6.6.8      RECEIPT OF MEDICINES INTO THE HOME.

All medicines from whatever source which are brought into a residential home must be
recorded as detailed below. This includes prescribed medicines, hospital discharge medicines,
medicines from a service user‟s home or those brought in by relatives and friends. This covers
conventional medicines and alternative remedies.

Details needed:-
   a. Date of receipt.
   b. Name of service user.
   c. Name, strength and dose of medicine.
   d. Quantity received.
   e. Signature of member of staff receiving medicines.

The quantities of the prescribed medicines received must be entered onto the service user‟s
MAR or recording chart, in the appropriate place on the chart, when they are checked off.
Some „when required‟ medicines may be carried over from one month to the next. If this
happens, the quantity received should be added to the quantity carried over so that the total
number of tablets in stock at the beginning of the 28 day period is recorded. In this way an
audit trail of tablet use is maintained.

      6.6.9 CHECKING PRINTED MAR CHARTS OR PREPARING PROFILES

If the supplying pharmacy also supplies printed MAR charts, these are usually delivered with
the monthly medicines. In addition to checking the medicines delivered, the information on the
MAR charts must be checked for accuracy. Particular attention should be taken to ensure that
any medicine changes during the previous month are reflected on the new MAR.



                  Please ensure that quantities of any carried over „when required‟
                  medicines are entered onto the new MAR.

If Profile and Recording Cards are used, these should be prepared before they are needed for
the next monthly cycle and the information entered on them must be checked by another
manager. As above, particular attention should be taken of any changes to medicines during
the previous month.

      6.6.10 PATIENT INFORMATION LEAFLETS (PILS)

A patient information leaflet must be supplied by the pharmacy with each medicine, including
those supplied in MDS. These should be made available to service users who may wish to
read them. PILs provide a wealth of information and can be a useful reference source if they
are filed in alphabetical order in a ring binder using polythene pockets.




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6.7     STORAGE OF MEDICINES

All medicines must, at all times, be kept secure.

      6.7.1 STORAGE OF MEDICINES FOR SELF-ADMINISTRATION)

Service users who have custody of and administer their own medicines must keep them locked in
the secure storage drawer or cupboard in their room. They may keep medicine containers on their
person (eg in a pocket or handbag) so long as this does not place other service users at risk.

Self-medicating service users must be asked to keep their medication secure at all times to
prevent access by any other person.

Staff must be instructed to be alert to any signs of medicines not being kept secure and to report
any concerns to the Manager.

Duplicate keys for service users‟ lockable drawer or cupboards must be available in case a service
user loses their own key. These keys should be identified and kept secure at all times.

      6.7.2 STORAGE OF MEDICINES TO BE ADMINISTERED BY STAFF .

Medicines which are the responsibility of staff must, when they are not being administered, be
stored in a locked designated area or room. The keys to the medicines room must be in the
possession of the manager on duty at all times. They should not be part of the master set for the
home. Duplicate keys must be kept in a secure place known only to home managers or deputy
managers.

      6.7.3 SITE OF MEDICINE TROLLEYS AND CUPBOARDS

Ideally, all medicines should be stored in locked cupboards or a locked trolley inside a locked
medicine room which is only used for the purpose of storing medicines. Medicine trolleys must be
anchored to a wall when not in use.

The site of medicine cupboards should be determined by considering ease of access of the
medicines when they are administered and by considering maximum security. Medicines should
not be stored at a temperature above 25 degrees centigrade (It may be necessary to record the
temperature of the room if it is subject to seasonal variation.) Medicines should not be stored in a
humid atmosphere. Permanent storage sites, therefore, should not be located near to a heat
source or within a humid environment, eg above a radiator or in the kitchen. Whenever possible,
cupboards should be sited away from windows to prevent observation by passers-by and away
from busy thoroughfares in the home.

A secure place must be available for storage of the monthly medicines delivery when it arrives,
until it can be checked and eventually put in the cupboards and/or trolley from which the medicines
will be administered. Deliveries must not be left on the floor of the medicine room.




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      6.7.4 CUSTODY AND STORAGE

     a. All the prescribed medicines for internal use for each service user should be kept together.
        Most establishments now receive solid dose medication in monitored dose blister cards
        which are stored on specially designed metal holders. A medicines trolley which can
        accommodate these should be used. For solid dose medicines which are received in
        traditional dispensing bottles or packs, individual drawers or compartments for each service
        user are recommended. If a cupboard is used, this should be large enough to allow each
        service users‟ medicines to be grouped together.

     b. Medication for external use should be kept in a separate locked cupboard or within a
        distinct area within a cupboard (compartment). It will probably be more practical for creams,
        ointments and lotions which are in use to be kept in service user‟s own rooms as they will
        usually be applied there. The preparations must, however be kept securely locked within
        the rooms.

     c. Eye, ear or nose preparations and inhalers may be kept with medicines for internal use.
        That is, they should also be locked away securely.


                  Standard 9 of the National Minimum Standards states that there is a
                  requirement that medicines be retained for a period of 7 days upon the
                  death of a service user in case there is a coroner‟s inquest.

      6.7.5      COLD STORAGE

Medicines which required cold storage should be identified in a delivery by the supplying
pharmacy, please ask you pharmacy to do this if they do not already do so. If needed, a suitable
letter requesting identification of fridge lines and Controlled Drugs in deliveries can be found at
Appendix 16. Items for cold storage should be placed in a bag or box clearly labelled, „FRIDGE
LINES‟. This should allow such medicines to be placed immediately upon delivery into the
medicines fridge in order to maintain the „cold chain‟.

Every N.C.C. Care Home[Registered] has been supplied with a lockable medicines fridge for
medicines requiring cold storage. The fridge must be kept locked at all times even if it is inside a
medicines room. It is important that the temperature inside the medicines fridge does not rise
above 8⁰C or fall below 2⁰C at all times. To ensure this, an appropriate maximum/minimum fridge
thermometer must be used, an ordinary fridge thermometer will not do. The maximum and
minimum temperatures reached in the medicines fridge must be recorded daily. A suitable chart is
available for this (Appendix 13) and it should be kept in a polythene sleeve attached to the door of
the fridge, checking the temperatures should be the responsibility of the manager on duty.

It may be necessary to adjust the setting of the fridge in order to maintain the correct temperature
through seasonal changes. If the temperature inside the fridge varies outside the designated
range, the fridge should be checked for correct operation and, if necessary, replaced. Medicines
fridges should be cleaned and defrosted regularly. This should be recorded on the medicines room
cleaning log.


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Certain products, e.g. suppositories and some creams are specified by manufacturers to be stored
in a cool place. These products may not necessarily require refrigeration. For further information or
guidance you should contact the community pharmacist.

6.7.5.1 STORAGE OF INSULIN

It is recommended that insulin should be at room temperature when it is injected. Please refer to
the Patient Information Leaflet (PIL) in the pack of insulin.

Insulin which is not „in use‟ must always to be stored in the medicines fridge. Vials and/or
cartridges and pens of insulin which is being used should be stored at room temperature either in
secure storage in the service user‟s room or in a locked cupboard in the medicines room.

It is imperative that insulin remaining in the fridge and that which has been removed for use is all
fully labelled, as it is on receipt from the pharmacy. Managers should liaise with the pharmacy to
devise a system that ensures that every single vial of insulin is labelled and that when a cartridge is
removed from the pack and put into an insulin pen, that the pen is contained in a fully, up to date,
labelled box.

Most insulin is stable for four weeks at room temperature and some is stable for six weeks. This
information is stated on the patient information leaflet. If in doubt, opt for four weeks.


                  When insulin is removed from the medicines fridge the date of removal
                  MUST be written on the container and on the MAR. A note must also be
                  made of the date after which the insulin must no longer be used and the
                  container of insulin MUST be replaced at this point.

6.7.5.2 RE EYE DROPS REQUIRING COLD STORAGE

Some eye drops which are required to be stored in a fridge (eg Xalatan) may be removed from the
fridge when in use and will remain stable for four weeks. This information is stated on the patient
information leaflet contained in every pack of eye drops. If eye drops are to be kept at room
temperature for use, the date of removal from the fridge MUST be written on the pack and the
MAR and the item replaced after four weeks.


                    Note: This does not apply to all eye drops which require cold storage so
                    please refer to the Patient Information Leaflet (PIL) in each case. If
                    service users prefer eye drops straight from the fridge, this will do no
                    harm.

      6.7.6 STORAGE OF CONTROLLED DRUGS

The receipt, storage and administration of Controlled Drugs (CDs) is strictly controlled and
documented. Detailed instructions are set out below. To help with identification of CDs, a list of
prescribed CDs is included at Appendix 14. A single sheet of simplified instructions for completion


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of the CD Register is available at Appendix 15. This can be photocopied, folded and stuck onto the
inside cover of the CD register for quick reference. It is imperative that the instructions concerning
CDs are adhered to accurately.


                  NB: CDs which are not used must be documented and returned to the
                  pharmacy for destruction.

The community pharmacist is not required by law to identify a Controlled Drug in a medicines
delivery. However, it is good practice when delivering to a residential home to do so. Please ask
your supplying pharmacy to pack any Controlled Drugs in a separate bag or box clearly labelled
CONTROLLED DRUGS so that they can be retrieved from the order immediately on delivery,
checked, entered in the CD register and locked away in the CD cabinet.

It may be appropriate to ask the pharmacy to telephone you if a delivery contains CDs so that they
can be dealt with on delivery. UNDER NO CIRCUMSTANCES MUST CONTROLLED DRUGS BE
ALLOWED TO REMAIN OUTSIDE THE CONTROLLED DRUGS CABINET. (This does not apply
to controlled drugs which may be taken by service users who self-medicate.)


                  Please note that the CD cabinet must only be used for the storage of
                  Controlled Drugs. It is not a safe and may not be used for the storage of
                  valuables!

      6.7.7 QUANTITIES OF MEDICINES IN STOCK

As a general guide, 28 days supply of medicines should be kept in the home for any individual.
The supply for the following 28 days should be requested half way through the period so that a
maximum of 42 days supply may be held at any one time.

6.8     ACCESS TO MEDICINES


      6.8.1 B5.1 STAFF AUTHORISED TO ADMINISTER MEDICINES

6.8.1.1 DESIGNATED OR NOMINATED OFFICER

Medicines must be administered by a designated or nominated officer, usually a Team
Manager,     Team Leader , who has received appropriate accredited training in the
administration of medicines; evidence of which should be on file.

6.8.1.2 CARE STAFF

Care staff who may be required to assist with administering medicines should have received
appropriate, accredited training.




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6.8.1.3 NON-NOMINATED CARE ASSISTANTS

Only in exceptional circumstances is it permissible for an untrained care assistant to
administer medicines to a service user. This might happen when a manager is on duty and
needs some assistance with distributing medication and no trained assistants are available. In
such circumstances, the manager takes responsibility for the correct administration of the
medication. A Care Assistant must only take medication for one service user at a time.

      6.8.2 KEY SECURITY

Keys to medicine cupboards, trolleys and other places where medicines are stored must be
clearly identified and kept in the possession of the designated or nominated officer(s) on duty.
At a change of shift, the keys must be handed by the outgoing manager to the manager who is
replacing him/her. Keys must not be left in a designated place to be collected later.

6.8.2.1 LOCATION OF KEYS

Location of spare keys should be known only to the designated and nominated officers. The
location should be secure but always accessible.

6.8.2.2 LOSS OF KEYS

Losses of keys must be reported to the designated officer and, if missing keys are not
recovered within a short period, the locks must be changed.

6.9 CONTROLLED DRUGS



      6.9.1 DEFINITION

All medicines are classified according to law so that appropriate safeguards regarding the
acquisition, storage, custody and destruction of medicines can be made. An important legal
category is that of Controlled Drugs (CDs). Medicines that are classified as Controlled Drugs
are defined in the Misuse of Drugs Act 1971 as “dangerous or otherwise harmful drugs”. The
primary purpose of the Misuse of Drugs Act is to prevent the abuse of Controlled Drugs. The
Misuse of Drugs Regulations classifies Controlled Drugs into five schedules according to
different levels of control. However, only Schedule 2 and Schedule 3 Controlled Drugs are
likely to be of relevance to Residential Homes.

      6.9.2 IDENTIFICATION OF CONTROLLED DRUGS

There is no legal requirement for community pharmacists to identify in writing the legal
category of medicines that are dispensed on FP.10 or private prescriptions. Where the legal
category of a medicine has not been identified in writing as a CD, the guidance provided in
Section B of the Medicines Code on the access, storage, supply, administration and disposal


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of medicines applies. Medicines identified as CDs must be recorded and stored as set out in
this Section.

It is necessary that you are aware when a service user uses Controlled Drugs and that you are
able to identify such drugs when they are delivered to the establishment. A suggested letter is
included at Appendix 16 to be sent to your supplying pharmacy requesting that CDs (and also
fridge lines) be identified in any delivery.

There may be occasions when CDs are received without being identified, for instance within a
collection of medicines brought with a service user on admission. Such CDs must be recorded
and stored in the same way as those received from a pharmacy. To help with the identification
of such medicines, a list of Controlled Drugs follows at Appendix 14.

It is unlikely that non-prescribed controlled drugs (i.e. drugs used by drug abusers), would be
received into a residential or day care establishment but should these be identified, (you may
need to contact the pharmacy or the police to do this), they should be isolated and handed
over to the police.

Once Controlled Drugs have been officially identified in writing, the procedures described
below MUST BE FOLLOWED.

      6.9.3 SUPPLY AND RECEIPT OF CONTROLLED DRUGS

Controlled Drugs may only be supplied via an individual FP.10 or private prescription issued
by a medical practitioner who is authorised to prescribe Controlled Drugs. On receipt of the
Controlled Drugs, the Designated or Nominated Officer, with a suitable witness (ie another
member of staff or the community pharmacist) must check the contents of the container with
the quantity on the container label. Any discrepancy must be reported to the community
pharmacist at once. If correct, the Designated or Nominated Officer must enter the quantity
into the Controlled Drugs Register on the appropriate page (see B6.8 for method of obtaining
Controlled Drugs Register). The balance of the drug now in stock must be calculated, checked
and entered at this time. The Designated (or Nominated) Officer and witness must sign the
register. If the drugs are correct they must immediately be locked in the appropriate Controlled
Drugs cabinet.


                  The Health Act 2006 which comes into force on 1 January 2007, imposes
                  further controls on the movement of Controlled Drugs. You may find that
                  your pharmacy asks for proof of the identity of the person collecting or
                  receiving Controlled Drugs (e.g driving licence).



6.10 STORAGE OF CONTROLLED DRUGS

Controlled Drugs must be stored in a suitably locked cabinet which complies with the Misuse of
Drugs (Safe Custody) Regulation 1973. Controlled Drugs cabinets have been supplied to all



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establishments. Cabinets should, where possible be installed in the medicines room and attached
to a brick or block wall in accordance with the installation instructions. In the case of
establishments which do not have a medicines room, the CD cabinet should be sited in an
appropriate private area away from public view, attached to a brick or block wall. Keys to the
Controlled Drugs cupboard must be kept in the possession of the manager or designated officer
on duty.



6.11 ADMINISTRATION OF CONTROLLED DRUGS

In addition to the procedures relating to the administration and documentation of other medicines
the following additional procedures must be carried out:

   I.     The administration of a Controlled Drug must be witnessed by a second, suitably trained,
          member of staff (senior staff or care assistant). A care assistant should only be asked to
          witness the administration of a Controlled Drug if a member of senior staff is not available.

  II.     An entry must also be made in the home‟s Controlled Drugs Register, including:

          1.   date and time of administration;
          2.   name of service user;
          3.   dose administered;
          4.   signature in full of giver and witness;
          5.   Remaining balance of stock, which should be checked on returning stock to the
               cupboard?

A separate page must be used for each service user and each drug and strength.

Appendix 15 has detailed guidelines for the completion of a CD register.

This has been prepared so that the sheet can be photocopied and attached to the inside cover
of the CD Register as an aide memoire.

 III.     Any Controlled Drug prepared for administration and not used, or only partly used,
          must be destroyed in the presence of a second member of staff (senior or care
          assistant). An entry must be made in the Controlled Drugs register and signed by both
          parties.

 IV.      Any discrepancies must be brought to the notice of the Designated Officer and/or the
          Community Pharmacist. Discrepancies must be investigated by the Designated Officer
          as soon as possible after discovery and an explanation made on the CD record, (within
          48hrs). Previous entries in the CD register must not be altered if a recording error is
          identified at a later date. A clear and legible explanation of the recording error must be
          made in the register.




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6.12 DISPOSAL OF CONTROLLED DRUGS (## 9.5)

If, a Controlled Drug is no longer required, (the medicines may have been changed or the service
user may have died) it must be disposed of by returning to the supplying pharmacy. Details of the
controlled drug(s) returned must be entered in the CD register and in the Returned Drugs Book
and a signature obtained from the pharmacist (or the delivery driver accepting the return and the
pharmacist.) You may need to telephone the pharmacy to inform them that a CD is being returned
as they will have a special protocol for disposing of it.

The following details should be recorded:-

     1.   Date
     2.   Name of service user
     3.   Controlled Drug name and strength
     4.   Number (or volume) of tablets (or liquid)
     5.   Signature of the Designated or Nominated Officer
     6.   Signature of witness witnessing the entry in the Controlled Drugs Register

Transdermal patches (eg Durogesic or Transtec patches) must be rendered unusable before
disposal. This is done by folding the patch in half with the adhesive edges joined thus sealing the
transdermal surface so that the drug could not be absorbed through the skin of anyone who may
handle the patch.


                  The Health Act 2006 which came into force on 1 January 2007 imposed
                  further controls on the movement of Controlled Drugs. It is recommended
                  that if you have to dispose of Controlled Drugs that you ask for proof of
                  the identity of the person taking or receiving the CDs and that you make a
                  note of this in the CD Register.

                  Similarly, if Controlled Drugs are removed from the home because the
                  service user is moving to another location, details of the circumstances
                  and people involved and their identification documentation should be
                  noted in the CD Register.

6.13 RECORD KEEPING FOR CONTROLLED DRUGS

All administration records that are required and described in the Medicines Code must be
completed. In addition, the records described must be completed, where appropriate.
Similarly, records of destruction as described must be completed if appropriate.

Entries in the CD register must be clear and must never be changed or obliterated. If a
discrepancy is discovered, it must be investigated and an explanation added to the register so
that it is quite clear what has happened.

6.14 CONTROLLED DRUGS REGISTER




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A suitable and appropriate Controlled Drugs Register may be obtained from Medipost, tel:
01305 776917.

7     MEDICATION REVIEW BY A GP

Review is necessary to ensure that service users receive maximum benefit from medicines that are
prescribed on a basis. The responsibility for prescribed medication ultimately rests with the service
user‟s GP. However, since the initiation of a repeat prescription depends upon the staff to request
a further supply, that individual should therefore participate in the review process. The community
pharmacist is ideally placed to provide additional assistance to service users and to staff on the
review of medication. The stages that should occur in the review of repeat prescriptions are as
follows:

7.1     MATTERS TO BE CONSIDERED W HEN REVIEWING REPEAT PRESCRIPTIONS


      7.1.1 OPINIONS OF THE SERVICE USER

          a. Is the service user satisfied with the medicines they take?

          b. Are there any apparent undesirable effects caused by the medicines?

          c. Is the medicine still needed? Has the service user‟s condition, for which the medicine
             was originally prescribed, been resolved?

          d. Is the medicine actually being taken by the service user?

          e. Does the service user feel that they are taking too many medicines?

      7.1.2 OPINIONS OF STAFF

          a. Does the service user seem well? Has he/she improved, got worse or has there been
             no change?

          b. Have staff noticed any change in behaviour of the service user?

          c. Has the service user had any slips, trips or falls?

          d. Has there been any recent change in medication?

          e. Has the service user been refusing medication?

      7.1.3 POINTS TO RAISE WITH THE GP/COMMUNITY PHARMACIST:

          a. Is the medicine still necessary for the medical condition?
          b. Is there an alternative medicine if the service user is experiencing side-effects?
          c. Is there an alternative preparation, eg liquid instead of tablets




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          d. (or vice-versa); a different strength of tablets to avoid splitting in half? Would a
             capsule instead of tablet facilitate swallowing?
          e. Could the number of administrations per day be reduced to facilitate self-
             administration?

          f.   The GP should review each service users‟ medication regularly. Should staff have
               any concerns about a particular service users‟ medicines, they may wish to raise
               these with the GP or community pharmacist.

7.2     FREQUENCY OF REVIEW

The National Service Framework for Older People (2001) states that GPs are required to
review all their patients over the age of 75yrs annually. Patients over the age of 75yrs and
taking four or more medicines regularly must have a medication review every six months. It is
in the interest of service users to keep an eye open for any problems associated with the use
of medicines. Ideally, the service user, staff, GP and the community pharmacist should all be
involved so that a review process may be discussed. In order to promote the regular review of
medication, staff should be encouraged to ask the community pharmacist to conduct a limited
regular review (max 2 per quarterly visit). When appropriate the community pharmacist should
communicate with the GP with regard to reviewing the medication.

7.3     MEDICATION REQUIRING REGULAR MONITORING

A number of drugs are prescribed which require regular monitoring to ensure that the dose is
appropriate. This is usually done by means of a blood test at regular intervals. These drugs
include warfarin, thyroxine (or levothyroxine), lithium (Priadel), insulin and oral anti-
diabetic drugs. Each surgery will have a system for carrying out these tests. If a service user
is prescribed a drug which requires regular monitoring, the establishment manager should
liaise with the appropriate person at the surgery to establish the frequency and way in which
the tests will be done. Details must appear in the service user‟s care plan and the date of the
next test be noted in a prominent way so that managers are aware when tests are due and
when they have been done. Following a test it may be necessary to change a dose and the
system laid down must be followed to ensure that the new dose is logged and set up on the
MAR.

7.4     PRESENCE OF A MEMBER OF STAFF DURING DOCTORS‟ CONSULTATIONS

Service users have the right to see the doctor alone or to have a member of their family, a
Carer or an advocate present during consultations with a GP. Consent should always be
sought from the service user prior to anyone apart from the GP being present. This may not be
possible if the service user is not capable of making a decision, such as in the case of
confusion or learning disability, the presence of staff is considered desirable because the
service user may not be able to recall the doctor‟s advice.




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8     PRESCRIPTIONS LEFT BY A VISITING DOCTOR

If a visiting doctor leaves a prescription for a service user for medicines which are needed for
immediate administration, the staff should, either take the prescription to the pharmacy to be
dispensed or telephone the pharmacy and provide details of the prescription in order that the
pharmacies may deliver as soon as possible. Most pharmacies will require the prescription to
be faxed, prior to delivery, so that the details can be confirmed before the dispensed item
leaves the pharmacy. The original prescription can then be collected by the person delivering
the medicine and taken to the pharmacy.

8.1     OUTSIDE OF NORMAL PHARMACY HOURS

If a doctor visits a service user out of normal hours (at night or at the weekend) and requires
the service user to receive new medicine immediately, he/she will leave a prescription for the
medicine and possibly a supply of the first few doses. If an urgent prescription is required
outside of normal pharmacy opening hours, the prescription form should be endorsed
„URGENT‟ by the doctor. A prescription marked „URGENT‟ may be presented to a community
pharmacy for dispensing outside of usual shop hours. Establishment managers are urged to
discuss with the local community pharmacist where late night community pharmacy services
are to be found and how or where prescriptions can be obtained when pharmacies are closed.
This information together with relevant telephone numbers must be available at all times. A
suitable place would be with information for contacting NHS Direct, the telephone number for
which is 0845 4647.

                  If it is known that it would not be possible to obtain medicines out of hours
                  because no arrangements exist locally, this should be discussed with the
                  visiting doctor before he/she leaves the home.



9     EMERGENCY SUPPLIES OF PRESCRIPTIONS ONLY MEDICINES
A community pharmacist is permitted to make „Emergency Supplies‟ of prescription only
medicines under very strict conditions. Emergency supplies may be made at the request of a
prescriber or at the request of a patient, or in this case their representative. We are only
interested here in the latter case. The pharmacist must be satisfied that:-

      a. There is an immediate need for the medicine and that it is not practical to obtain a
         prescription.
      b. That the medicine has been prescribed on a previous occasion.
      c. No more than five days medication can be supplied (except for complete packs such as
         a cream or an inhaler)
      d. Controlled Drugs may not be supplied in this way.

                  It should be noted that the community pharmacist may make a charge for
                  an emergency supply as it will not be covered by an NHS prescription.



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10 MEDICINES FOR EMERGENCY USE

Supplies of Prescription Only Medicines for emergency use should not be kept in stock (except
for specific products for named individuals – eg Glucagon injection for diabeties or diazepam
suppositories for epilepsy, however, only staff who have been specially trained may administer
such treatments). The administration of these medicines, however, falls outside the scope of
this Medicines Code.

11 ADMINISTRATION OF MEDICINES

11.1 ADMINISTRATION BY THE SERVICE USER

Service user‟s who wish to administer their own medicines must be assessed as able to do this
and all the relevant forms must be completed and signed. (Appendices 6 & 7). Those service users
able to collect their own medicines from the pharmacy should be encouraged to do so if they so
wish. In practice, however, most medicines will be collected from the pharmacy or delivered by the
pharmacy in one operation each month. A record should be made of the medicines given to a self-
administering service user but it is not necessary to make any entries on MAR charts. Controlled
Drugs are treated in exactly the same way as other prescribed medicines, no extra records are
needed.

The community pharmacist should be informed which service users will be administering their own
medicines and an agreement reached about the most suitable dispensing container to be used.

A variety of aids is available to assist self-medication and should be encouraged where possible.
Advice on appropriate aids and their methods of use to ensure correct doses are taken should be
obtained from the pharmacist.


                  Under no circumstances must staff fill compliance aids for self-
                  administering service users



11.2 ADMINISTRATION BY STAFF

Medicines that are prescribed for service users should be administered in accordance with
procedures described below by using either i) a Monitored Dosage System (MDS) or ii) ordinary
medicine containers. Medicines prescribed for one person must not be used for any other person.
The preferred method for storing and administering medicines is the Monitored Dosage System.

Administration from traditional dispensing containers is acceptable. Whichever system is used,
staff involved in the administration of medicines must be familiar with the system.

11.3 TIMES OF ADMINISTRATION OF DOSES




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Reference should be made to the dosage instructions on the label of a medicine and possibly to
the patient information leaflet when deciding the time(s) of doses. If there is any doubt, contact the
pharmacist for advice. Pay particular attention to a dose stated as ONCE daily, to ensure that it is
given at the optimum time. Most once daily doses are given with breakfast but statins are best
taken at night.

Some medicines, for instance lansoprazole and some antibiotics, should be taken while the
stomach is empty between 30 to 60 minutes before food. Doses should indicate quite clearly
how the medicine should be given. A dose such as „take three daily‟ is unacceptable as it
could mean „take three at once‟ or „take one three times daily‟, such a dose must be clarified
before any medicine is given. The pharmacist will have put the medicines in an MDS system
into the appropriate dose times, however the question of before or with food should be
addressed if it is not stated on the label.


                  Where medicine is directed to be taken „when required‟, clarification must
                  be sought from the GP or pharmacist before it is needed. Ideally the
                  details should be printed on the medicine label but where space does not
                  allow this, precise details should be entered on the service user‟s care
                  plan and a reference to this be made on the MAR at the appropriate
                  place.



11.4 IDENTIFICATION OF SERVICE USERS

It is imperative that the documentation used to record the administration of medicines also includes
(for identification purposes) a current recognisable photograph of the service user. Passport
photographs are not clear enough and a minimum of 7.5cm square is needed.

11.5 DIRECT ADMINISTRATION

The administration of a medicine must be directly from the original dispensed container and only to
one service user at a time. There must be NO ”re-dispensing” of doses into secondary containers
in advance of a medicines round. The procedure for administering medicines described below in
Section B11.7 must be followed. The procedure also applies to the occasional administration of
medicines by nominated officers for instance a PRN (as necessary) dose of paracetamol.

11.6 RECORDS

A list of all staff in an establishment who are or who may be involved in administering
medicines must be available together with their signatures and their initials so that the identity
of anyone administering medicines can be established at any time. This includes deputy
and/or relief staff, who should ensure that their details are entered on the list before they
administer medicines in an establishment.




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Each dose administered by staff must be recorded on a MAR or Medication Recording Card
(Appendix 11) at the time it is given. The record must indicate the name and strength of the
medicine, the date and time of offering the dose and the initials of the member of staff who
offered the dose. The record must also indicate if a medicine is not taken when it is presented
and the reason for this (using appropriate codes). If there is an option to give one or two
tablets, the record must show how many were taken. The MAR or medication recording card
must provide a detailed picture of exactly what has taken place on a medicines administration
round. Section D, of the Medicines Code covers the use of recording documents in detail.


                  A MAR chart is a legal document. If problems occur regarding a service
                  user‟s medication, the MAR chart will be taken as an accurate record of
                  all medication administered and will be referred to for such information.
                  These documents are for the protection of staff as well as service users
                  and it is in the interests of both that they are completed accurately and at
                  the time of administration.



11.7 PROCEDURE FOR THE ADMINISTRATION OF MEDICINES BY CARE STAFF


Each establishment must have a written policy detailing this procedure and it must be ensured
that all staff involved in the administration of medicines are trained in the procedures used in that
establishment. This particularly relates to relief staff as there may be some variation from
establishment to establishment. The basic principles, however will be the same.


          If a service user takes medicines in an unconventional manner or needs more time or
          encouragement to take their medicines, this should be noted in the care plan and on the
          MAR so that anyone, particularly relief staff, who may be administering medicines is aware
          of the situation.

          Before starting out, wash and dry hands thoroughly and ensure that all utensils to be used
          are clean and dry. Have a jug of water and some glasses ready in case a service user does
          not have a drink to hand.

          Security of medicines must be maintained at all times. Medicines must be selected from
          the medicines cupboard or trolley which must be closed and locked if left unattended.

          If medicines are to be taken from one area of the home to another, other than in a trolley,
          (eg to a service user who remains in their room) it is essential that they are carried in a
          secure container or box so that if they were dropped, they could not be lost or spilled.

          Care Assistants may only take medicines to one service user at a time.




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     a. The service user is identified (by reference to a photograph if necessary). Great care
        should be taken when it is known that service users with the same or similar names are
        resident. It may be appropriate to mark the MAR charts of such service users with a
        warning, eg „Please note we have two ladies called Elizabeth Smith‟. In such a situation the
        date of birth should appear on the MAR, if the service user is known by another name that
        too could be included, Elizabeth Smith could be known as Betty. It would be possible to
        request the pharmacy to express her name as Mrs Elizabeth (Betty) Smith on medicine
        labels.

     b. The service user‟s MAR chart is turned to and the medicines found in the trolley/cupboard.

     c. Each medicine is checked in turn matching the details on the MAR with the details on the
        dispensing label, drug, strength, dosage instructions. Any changes in dose are checked for.

     d. By reference to the MAR, it is established whether a dose is due at this particular medicine
        round.

     e. Care should be taken that certain medicines which should be given before or after food are
        given at the correct time in relation to meals. It may be necessary to refer to the patient
        information leaflet or to the community pharmacist to establish the optimum time for
        administration.

     f.   The MAR is checked to ensure that the dose has not already been given.

     g. If the service user takes more than one tablet or capsule at a time, it will probably be most
        convenient to place all these into a small medicines pot and then hand this to the service
        user. Tablets and capsule should not be handled by staff as this could result in the
        medicines becoming contaminated either by bacteria on the operator‟s hands or with
        residue of other tablets.

          Tablets which are to be dissolved before administration should be put into a glass and
          sufficient water added to allow them to dissolve completely (about half a glass). They
          should be stirred and allowed to dissolve completely before being handed to a service user.


                  It should be noted that some tablets given in water do not completely
                  dissolve but DISPERSE. These should be added to a smaller volume of
                  water, allowed to break up and disperse and the liquid should be swirled
                  around before handing to the service user to ensure that no particles are
                  left in the bottom of the glass.

     h. The MAR should be initialled immediately after each medicine has been administered.
        Where there is a choice of dosage, e.g. 1-2 tablets, the record must show how many were
        taken. If a dose is not taken, the MAR should record this and the reason why it has not
        been taken. There should be a system of codes to record this.




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                  NB It is acceptable to put a small mark on the MAR chart as each
                  medicine is selected as a check that this has been done. Initials (or codes
                  in the case of medicines not taken) must not be added until after
                  administration has taken place.

     i.   For „when required‟ medication, the need for a dose should be established first, by discreet
          reference to the service user, and the details of the dose entered on the MAR as above.

     j.   Soluble tablets should be placed in half a tumbler full of water, stirred and allowed to
          dissolve before handing to the service user.

     k. Liquid medicines should be selected in the same way as tablets and capsules, the label
        being checked against the MAR. The bottle should be shaken well and the dose poured
        into a small medicine pot and handed to the service user.

     l. Managers should ensure that all staff who may be required to assist service users with the
        administration of eye drops, ear drops, nose drops and inhalers are competent to do so.
        The advising community pharmacist or a district nurse could be asked to give any training
        needed.
     m. Creams, ointments and lotions should be applied using protective barrier gloves. It will
        be preferable for these to be applied in private in a service user‟s room. Care must be
        taken to ensure, in this case that the application is recorded on the MAR or Recording
        Card in the same way as medicines which are taken.
          Products for topical application may be stored in a locked medicines cupboard reserved for
          that purpose, however it may be more practical for creams, ointments and lotions to be kept
          in the service user‟s own room. It must be remembered that if this is the case, they must be
          stored securely in the lockable drawer or cupboard provided and not left on an open self, in
          a bathroom, for example. A simplified MAR relating to the applications could be kept with
          them in the service user‟s room and marked by the Care Assistant after each application;
          however a record must also be made on the main MAR chart, this should be the
          responsibility of the person administering medicines.

11.8 REFUSAL OF MEDICINES

Service users should not be forced to take medicines against their will and no medicine should be
used as a means of punishment or social control. Most refusals are attributable to physical
problems or to fears and anxieties that can be resolved by expressions of care and concern. If a
service user refuses a dose of a medicine the medication record must be marked to indicate this. If
the service user is asleep and the dose is not given the record must be marked accordingly. Seek
advice from the community pharmacist or GP in the event of regular refusals or inability to swallow
a solid dose, alternative forms of medicines may be available (liquid instead of tablets) which may
be easier for the service user.

Very occasionally, it may be necessary to give medicine in food or drink because no liquid form is
available and the service user simply cannot swallow tablets. The suitability of the medicine to be




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given in this way must be checked with the community pharmacist and the details of the method of
administration must be documented, see Appendix 9.

11.9 SPOILED DOSES

Occasionally, a service user may drop a tablet or capsule on the floor or into their food so that it
cannot be given. The spoiled dose must be retrieved and put into a safe place (ideally a tablet
bottle kept on the trolley for such an eventuality). If medicines are supplied in a Monitored Dosage
System (MDS) the replacement dose needs to be selected from doses at the end of the 28 day
period, if in conventional packs, take another tablet or capsule from the pack.

In either case, a replacement tablet or capsule must be obtained from the pharmacy otherwise
medication will be short at the end of the month. A prescription will be needed for this replacement
dose. A note must be made on the MAR to indicate that the last dose of the month is in a separate
container.

11.10 TIMES WHEN MEDICINE MAY BE GIVEN IN FOOD

Service users have every right to refuse medication and they should not be forced or coerced into
taking medicines against their will. Medicine must not be given in food unless it is with the service
user‟s knowledge, for instance, because it is easier for the medicine to be taken that way. In such a
case, it is first necessary to confirm with the pharmacist that the stability of the medicine is not
impaired by being given in food or drink. Details of the medicine and the way it is given must be set
out in the service user‟s care plan and the service user (or a relative or carer) must be asked to
sign this to indicate that they are aware that the medicine is being given in such a way. This must
be done on Form SS/161a Appendix 9.

In the case of a service user with impaired mental abilities who refuses medication, the lack of
which would be detrimental to the health of that service user, a multi-professional team must be
brought together to consider the situation. The service user should be represented at any such
meeting by a relative, carer or other person who has the service user‟s interest at heart. Particular
attention and respect should be given to any previous instructions given by the service user, while
of a sound mind, which may have a bearing on the outcome of this meeting. If the conclusion of
this meeting is that it would be in the service user‟s best interest to give medication hidden in food,
details must be documented, using Document SS161b, (Appendix 10) and all involved in the
decision must sign the document.

While it is hoped that the GP will sign this form, if he/she will not sign but still agrees with the
method of administration, just note the doctor‟s name and the date on the form. The decision must
be reviewed, and a new document prepared and signed, every six months or sooner if the
condition of the service user changes. The pharmaceutical stability of the medication given in such
a manner should be confirmed with a pharmacist who in turn may need to refer to the
manufacturers for this information.

11.11 ALTERNATIVE REMEDIES




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It is recognised that there may be occasions when a service user or their family requests
medicines or alternative remedies (eg herbal/homeopathic) to be administered to that service user
by the staff. Staff must not administer these non-prescription medicines without checking with the
community pharmacist to ensure they are safe. In the case of alternative medicines, the community
pharmacist may need to contact other agencies (eg the Royal Pharmaceutical Society or the
National Pharmacy Association) in order to give an informed reply to your query. The service
user‟s GP should be informed if any alternative remedies are taken.

11.12 MEDICINAL OXYGEN

Medicinal oxygen has been supplied on prescription by community pharmacy oxygen contractors
for many years. Early in 2006 the provision of this service was transferred to AIR Products. If a
doctor decides that a service user requires a supply of oxygen, he or she will contact AIR Products
direct to organise the supply.

Managers should ensure that as many staff as needed are trained in the use of oxygen and that
the statutory warning notices (Compressed Gas. Oxygen: No Smoking, No Naked Lights) are
displayed outside any room where oxygen is used or stored.

In some areas of the country there have been logistical problems in transferring the supply of
oxygen from pharmacies to AIR Products, please work with your GP, AIR Products and your
community pharmacy oxygen contractor and be guided by them while this situation exists.

11.13 ERRORS IN ADMINISTERING A DOSE

An error in medicine administration is defined as any deviation from the prescribed dose. Should
an error be made or be discovered to have been made in the administration of a service user‟s
medication, the error and the circumstances surrounding it must be investigated and documented
as soon as possible. This is to ensure that any possible harm to the service user is attended to
urgently.

Errors result from a number of causes:- distraction, fatigue, trying to rush, human error or a
systems error. Identifying the cause of an error is important in deciding if any changes need to be
made to the way things are done in order to make the system safer and prevent a repetition of the
same error. This is part of risk management. Errors may vary in seriousness; however, prompt
attention must be given to all errors following the procedures set out in the Northamptonshire
County Council Adults Department, Medication Error Policy, which is to be found at Appendix 24 of
this Code.

Errors must be recorded on the Northamptonshire Adult Department Medication Error Report Form
(Appendix 25) and sent to Health and Safety Section and the Service Manager within 24hrs (Major
Errors must be reported to the Service Manager by telephone as soon as possible). A copy must
be retained at the home and filed under type of error. Reports of Errors must be subjected to
regular analysis as described in Near-miss incidents.




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11.14 NEAR-MISS INCIDENT REPORTING

A near-miss incident in relation to medication administration is an „error‟ which nearly happened
but was noticed and rectified before administration took place. Near-miss incidents should be
recorded on the Northamptonshire Adult Department Near-miss Report Form (Appendix 25) and
sent to the people designated on the form. A copy of the form must also be retained at the home
and filed according to error type.

Analysis of reports of errors and near-miss incidents can be used to help identify shortcomings in
systems which can be the cause of such incidents. Managers and Service Managers should
examine reports of errors and near-miss incidents regularly but at least twice a year, to identify any
common causes of errors and to arrange for changes in systems if these are the cause.

Managers becoming aware of systems or practices which could lead to errors are asked to inform
their Service Manager.

11.15 SUSPECTED ADVERSE DRUG REACTIONS (ADRS)

All effective drugs have some side effects, most of which do not cause problems. Many drugs
interact with other drugs and the computers used by doctors and pharmacists are programmed to
warn of interactions and grade them according to seriousness. However, occasionally a service
user may suffer an adverse drug reaction (or interaction). Particular care should be taken to
observe service users when a new drug is introduced and any untoward or unacceptable reactions
should be reported immediately to the GP or the pharmacist.

Adverse drug reactions, particularly unexpected ones are reported to the Medicines and Health
Products Regulatory Agency by GPs, pharmacists or nurses using the yellow card scheme (see
the back of the BNF). In this way information is logged centrally about new drug reactions.



12 ADMINISTRATION OF MEDICINES AWAY FROM THE CARE HOME

There are a number of circumstances which could lead to a service user taking medicines away
from the care home. The system used to ensure that they take their medicines correctly, at these
times, will vary from one situation to another.

12.1 ATTENDANCE AT DAY CARE CENTRES

The managers should confirm whether medicines are needed by the service user during their time
at the Day Care Centre. If medicines are needed, the two managers should exchange information
and arrange how the medicines will be sent to the Day Care Centre, this will depend on the
frequency of visits. Details should be entered on the service user‟s care plan and MAR.




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12.2 A SHORT UN-PLANNED ABSENCE (E.G. LUNCH OUT WITH A RELATIVE).

     a. Confirm that medication is needed during the absence.

     b. Place the required dose(s) into a suitable labelled container (tablet bottle or lidded pot). The
        label should clearly state the name of the service user, the number of tablets (there may not
        be space to list the tablets) and the time the tablets should be taken.


                          i. NB: Envelopes are not suitable for this purpose.

     c. Hand the medicines to the person who will be responsible for the service user during the
        absence.

     d. Record the details on the medication chart.



12.3 GROUP DAY TRIPS OUT FROM THE HOME

In the case of a day trip where managers and staff will accompany service users, medication
administration while away from the home must be treated in the same way as it would be in the
home. A suitable container should be found in which to carry the medicines and the administration
records, (eg a lockable brief case or a rucksack which can be secured with a pad lock). This should
be kept in the possession of a manager at all times (hence the usefulness of a rucksack.) In this
way medicines can be administered and recorded as they would be in the home.

12.4 HOLIDAYS AWAY FROM THE HOME

If a service user self-administers medicines, staff should ensure that they take their medicine away
with them and that they have sufficient for the whole of their time away from the home.

If a service user to whom medicines are administered is going to be away for a week or more it is
preferable, on grounds of safety, to obtain a separate prescription to cover the medicines needed
for the specific leave of absence. The pharmacy should be asked to supply the medicine in
standard dispensing containers or a compliance device, depending on discussions. This
circumvents the need for staff to re-dispense and label. A form of recording card should be
provided so that the person responsible for the service user while on holiday has information about
the medication and dose times. This would also be used if the service user needed to see a doctor
while they were away from the home. If the pharmacy usually supplies printed MAR charts, it may
be possible for a spare MAR chart to be printed for the holiday at the time that the holiday supply is
dispensed.

Only sufficient supplies of medicines for the period of absence should be taken away from the
home.




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13 DISPOSAL OF MEDICINES

13.1 GENERAL INFORMATION

Medicines should be disposed of as soon as a course of treatment is completed, discontinued, the
service user dies, or when the expiry date of the medicine is reached. However, since medicines
are the property of the service user, their permission should be sought prior to destroying
medicines on their behalf.

In the event of the death of a service user, the medicines should be retained for 7 days in case
they are required by the Coroner‟s Office.

There should be no need for large quantities of medicines to be destroyed if stocks of medicines
are regularly inspected.

It is good practice to check stocks of medicines as part of the monthly re-ordering process which
will allow identification of medicines no longer required and an evaluation of quantities of “when
required” medicines. Large establishments will probably find it necessary to return unwanted
medicines every month.

Team Managers/Team Leaders must ask the local community pharmacist to check the stocks of
medicines on a regular basis. A minimum frequency would be every six months. Any medicines for
destruction may be taken away by the community pharmacist at that time.

13.2 MEDICINES REMOVED FROM THE HOME

Please note that only Residential Establishments are able to return unwanted medicines to their
local pharmacy for destruction. Nursing Homes must make their own arrangements for disposal of
unwanted medicines. The nursing home manager must ensure that the medicines are disposed of
by a specialist licensed company who will provide documentation to substantiate this.

Appropriate records must be made of medicines that are removed from the home in addition to
medicines returned to the pharmacy. This could occur when a service user returns home, goes on
holiday, transfers to another establishment or is admitted to hospital. Medication returned to the
pharmacy from the home must also be listed in order to provide a full audit trail of medicines
through the care home.

The record should detail:-

     a. The date of disposal or return.

     b. The name of the service user.

     c. The name and strength of the medicine.

     d. The quantity returned.

     e. The signature of the person who prepared the medicines for return.


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A duplicate book must be used for returns to the pharmacy. This allows the returned medicines to
be listed and a copy of the list should be included with the returns going to the pharmacy. A
signature should be obtained from the pharmacy for all returns, however, if it is not possible
because of time constraints to get a signature from a member of the pharmacy staff confirming that
they have received the medicines as listed, it would be advisable to routinely get a member of the
care home staff to confirm the drugs for return and countersign the returns book.

Most pharmacies require medicines to be returned in original containers so that they can be
identified. Discuss with your pharmacist how they may require „spoiled‟ tablets to be returned.
Transdermal patches can be made safe for return or disposal by folding skin side surfaces together
so that the adhesive edges stick to one another enclosing any remaining medication in a sealed
„pouch‟.

13.3 CONTROLLED DRUGS .

Special arrangements must be made for medicines that are identified as Controlled Drugs in the
case of which a signature must be obtained from the pharmacist because the Misuse of Drugs Act
and relevant regulations must be observed.



14 HOUSEHOLD REMEDIES


14.1 GENERAL INFORMATION

A small range of products may be kept in stock for the treatment of minor ailments. These
“household remedy” products should be purchased from a pharmacy. Household remedies fall into
two legal categories, GSL (General Sales List) or „P‟ (Pharmacy Only Medicines). Medicines falling
into these categories may also be prescribed for service users, any such medicines which are
obtained on prescription must only be administered to the individual specified on the container
label. They may not be used as a source of stock for the household remedy cupboard. All
administered doses of household remedies must be recorded in the medication recording
documents according to the procedure described.

Household remedies must not be used for more than three days without referral to the service
user‟s GP.

The Northamptonshire Older Adults Department Household Remedy Policy will be found at
Appendix 21

A suggested list of household remedies and their uses may be found in Appendix 22 .

Flow charts to help in the use of household remedies will be found at Appendix 23.

These three documents may be photocopied and kept with the household remedies.




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15 MEDICINES PURCHASED BY OR ON BEHALF OF SERVICE USERS

Service users and visitors may sometimes purchase medicines and bring them into the home. It is,
of course, a person‟s right to be able to do so, but it is often not in their own interest. The use of
purchased medicines in addition to those prescribed by the GP may constitute a health risk due to
interactions between medicines. Alternatively, additional medication may have an adverse effect
on the condition being treated. When a service user is first admitted to the home they should
therefore be asked not to purchase medicines without notifying the Responsible Person in Charge.
If a service user does acquire medicines in this way, the safeguards discussed regarding self-
administration of medicines should be carefully considered.

Any purchased medicines must be stored in the same place as prescribed medicines. Service
users who administer their own medicines will therefore have custody of their own purchased
medicines. Purchased medicines for service users whose medicines are administered centrally
should be labelled with the service user‟s name and stored with the other medicines.

Where service users wish to take purchased medicines in addition to prescribed medication,
advice must be sought from the pharmacist that they are both safe to be taken simultaneously.
This advice also applies to service users who administer their own medicines. The service user‟s
GP should be informed of medicines taken other than prescribed medicines.

Any restriction or other advice obtained must be given to the service user concerned.



16 DAY CARE SERVICES

16.1 INTRODUCTION

Service users may attend for day care at locality Day Opportunities, specialist day care centres or
at a number of residential homes which have places available for day care. The administration of
medicines to such service users is similar in all situations.

     a. Day care services exist for a number of reasons:-

     b. To provide the service user with a change of environment and hopefully social interaction
        with other service users, whilst also providing vocational opportunities and community links

     c. To provide carers with a much needed break and support.

     d. In a number of cases, to provide support and training to enable the service user to become
        independent or to sustain living in their own home.

16.2 THE INITIAL ASSESSMENT

Most service users attending day care will live at home alone and may or may not have any other
input into their care. Some will live with a relative who cares for them or with a paid carer,



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occasionally a service user in Day Care may live in a Residential Home or in a Family placement..
Service users attending day care may or may not be capable of administering their own medicines
and this should be established at the initial assessment in addition to identifying any medical
condition and obtaining a full list of medicines taken (whether taken at the day care establishment
or not). This gives managers an overall picture of the service user‟s medical condition and
treatment, information which would be necessary if the service user required medical attention
while at the centre.

16.3 GATHERING INFORMATION.

Before the service user attends day care, medication information should be gathered in the same
way as set out in (Medication Information on Admission to a Residential Establishment)

A member of the assessment team may visit the service user and collect and collate the required
information. A Manager or Team Leader may visit the service user at home before they attend day
care. Much useful information can be collected at such a visit about medicines and about the
service user‟s ability or not to administer their own medication. The manager can also explain the
importance of safe custody of medicines and if the medicines are to be administered by care staff,
discuss how they should be packaged and sent to the day care centre.

If it is not possible for a manager to make a home visit, a letter should be sent to the service
user, or carer, requesting the necessary information. A suggested letter is included at
Appendix 18.

17 CHANGES TO MEDICATION

A problem experienced by day care establishments is that of keeping up with changes to service
user‟s medication. The medical certificate issued by the GP, Appendix 30, is updated annually but
service users can have many changes of medication in a year. Service users or their carers should
be asked, regularly, to inform staff of any changes in medical condition or medication so that the
information held can be accurate.

If medicines are administered by care staff and new or different medicines are brought by the
service user, confirmation of the new medication should be sought from the GP or possibly the
supplying pharmacy. It should however, be remembered that both GPs and pharmacists are bound
by rules of confidentiality and are unlikely to divulge confidential information over the telephone
unless they know who they are speaking to. It is always helpful to establish a good working
relationship with local surgeries and pharmacies. This can be more difficult when service users are
not local and thus their GP and pharmacist are not known by you. In this situation initial contact will
probably have to be made by letter.

18 SELF-ADMINISTRATION AND COMPLIANCE AIDS

Service users who attend residential homes for day care are likely to be in charge of their own
medicines. Therefore, if a service user requires assistance with medication this should be given,
but always bearing in mind the importance of maintaining their independence. It is anticipated that


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the majority of these service users will have custody of, and will be responsible for administering,
their own medicines whilst attending the centre.

If a service user is capable of understanding how and when to take their medication, but has
difficulty in remembering to take it, then the use of a Compliance Aid may be appropriate. The
decision to use a Compliance Aid must be made after discussion with the service user and also
with the service user‟s carer if appropriate. The guidance given (Containers for Self-Administering
Service Users) on the use of Compliance Aids applies to day care service users in residential
homes.

Managers may consider it helpful to use all or part of Northamptonshire Older Adults Department
Risk Assessment Form for service users wishing to self- administer medicines (Appendix 6) in
order to determine if a service user is able to control their medicines and understands the need to
keep medicines secure.

One of the purposes of day services is to provide service users with skills to help them become
self-sufficient, to achieve a sense of personal fulfilment and to enable them to gain normal
employment whenever possible. Therefore, service users should have the opportunity to take
custody of their own medication if they are capable of doing so. If a service user is not currently
capable of taking custody of their medication, consideration should be given to the provision of
training.

18.1 SURRENDERING MEDICINES TO STAFF

Service users should not be required to surrender their medicines to staff unless it is the express
wish of the service user and/or carer. If this is the case, the procedure described in must be carried
out.

18.2 COUNSELLING ON ADMISSION

When a day care service user first attends a residential home, he/she should be counselled on the
importance of keeping medicines safely on his/her person.

18.3 EVALUATING RISK TO THE SERVICE USER

Although independence and self-determination are of paramount importance, it is the duty of staff
to keep an eye open for any obvious confusion among service users with respect to their
medication. This does not mean implementing a strict system of observation. It is more appropriate
to be on the look-out for any misplaced doses of medicines, eg doses placed on table tops or
dropped on the floor. If medicines are being looked after properly by service users, there should be
no evidence of any medication except when service users are actually taking medicines.

18.4 EVALUATING RISK TO OTHER SERVICE USERS

It is just as important to assess the impact of an individual service user upon others. Therefore,
staff should ensure that service users do not offer their medicines to other people. Service users



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should also be extremely vigilant with regard to the safe storage of their medicines. If a service
user disregards these important safeguards they should be counselled. If persistent counselling on
this matter is required it may be necessary, in the interests of safety, for staff to administer their
medication.



18.5 INABILITY TO SAFELY SELF-ADMINISTER MEDICINES

There may be occasions when a service user is considered no longer able to administer their own
medicines without putting themselves or others at risk. If so, the matter should be discussed with
the relative or carer prior to staff taking full responsibility for the administration of medicines. The
completion of declaration of self-custody forms SS/159 and SS/160 (Appendix 7 and Appendix 8)
is optional for service users receiving day care.

19 ADMINISTRATION OF MEDICINES BY STAFF

In order to try and reduce the number of medicines given by staff at Day Care Centres it is always
worth contacting the service user‟s community pharmacist (who may then liaise with the GP) to see
if any dose times can be moved or if different formulations of a drug can be prescribed which would
allow for all the medication to be taken at home. Obviously such changes would have to be
discussed with the service user, or their carer(s). Such rationalisation often has the effect of
simplifying the service user‟s whole medication pattern and makes life at home easier too.

Service users who require their medicines to be administered by staff should be identified on their
initial assessment. The information about medicines gathered at the manager‟s or Team Leader‟s
home visit, or supplied by the service user or carer if no home visit is made, must be entered onto
the service user‟s Care Plan. Arrangements should be discussed at that time regarding which
medicines will be sent to the day care centre, when they will be sent and, importantly, how they will
be packed and labelled. Only medicines received in original packs and bearing a recently dated
pharmacy label can be accepted for administration by staff. On receipt at the day care centre, the
medicines must be recorded as detailed in (Receipt of Medicines into the Home). Administration
details must be written up onto a spare MAR or a Profile and Recording Cards and this must be
checked by a second member of staff for accuracy.

Quantities of medicines received for day service users will vary. The medicines may simply be
brought in daily, however, if the service user attends the centre several times in a week, an
agreement may be made for all the medicines required to be administered at the centre in that
week to be brought at once. No more than 20 days medication should be received at one time.

Regular enquiries should be made of service users and carers to find out if any changes to
medication have taken place, particularly if it is known that a service user has been in hospital.

Particular attention should be paid, when listing medication brought in by service users that the
medicines, strengths and dosages have not changed from those listed last time. If a change is
detected, this should be confirmed with the GP or pharmacy. It is for this reason that it will be seen
that only recently dispensed medicines should be brought in. An examination of the medicines


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should also be made to ensure that the pack or bottle contains the tablets or capsules described
on the label (if in doubt, contact the pharmacy).

Medicines which are to be administered by staff must be stored and administered according to the
protocols set out in (Storage of Medicines to be Administered by Staff) and (Administration of
Medicines). However, not all of this will apply to day care centres.

It will thus be seen that day care centres will require suitable storage facilities for medicines
administered by staff though probably not a trolley. If Controlled Drugs are administered by staff, a
separate Controlled Drugs cabinet must be available and entries must be made in a CD register,
see Appendices 14 & 15



20 PROVISION OF OUTREACH SERVICES

Where staff are required to leave their base and provide outreach services to service users, the
systems outlined in Section C above should be adopted for a template from which to draw up
detailed policies and procedures which will depend on circumstances and the facilities at the
venue.

Every effort should be made to prepare an information form for each service user, such as the
Hospital Admissions Form (Appendix 20), so that relevant information is available in case a service
user requires medical attention.

This is necessary because service users and staff require a legal safeguard should anyone be
asked to justify their actions.



21 MEDICATION DOCUMENTS AND PROCEDURES                                                            FOR   ADMINISTERING
   MEDICINES (ALL ADULT ESTABLISHMENTS)

21.1 THE PURPOSE OF MEDICATION RECORDING DOCUMENTS

The purpose of a medication recording document is to enable all staff (and service users if
appropriate) to trace the use of a medicine from the time it is requested to the time it is
administered or destroyed. It is primarily a source of information so that staff and appropriate
professionals can find out who administered a certain dose when and to whom. The records will be
an aid to correct administration of medicines, although they do not necessarily ensure that a
person has actually swallowed a dose that has been offered. Medication records help to ensure
that all staff are aware of the quantity of medication present and will reduce tendencies to over
order (or over request) repeat prescription medicines.

The recording documents serve as a legal safeguard for service users and staff should anyone be
asked to justify their actions.




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21.2 GUIDELINES FOR COMPLETING MEDICATION RECORDING DOCUMENTS

The following guidelines will help you to complete the records efficiently and meaningfully. If, after
reading this Medicines Code, you are still not sure how to complete the records, please consult
your Designated Officer or the Community Pharmacist.

      21.2.1 PRINTED MAR CHARTS SUPPLIED BY THE PHARMACY

Most establishments now receive MAR charts from the pharmacy when the monthly supply of
medicines is delivered. The great advantage of these documents is that the information on them is
drawn from the labelling programme on the pharmacy computer which ensures the accuracy of the
information. Also the need for home managers to record by hand onto recording documents is
eliminated, saving time and reducing the risk of errors in transferring this information. Many of
these printed MAR charts also incorporate duplicate sheets which can be used to record and order
further supplies of the repeat medicines each month. The pharmacist will explain the use of printed
MAR charts when they are first introduced to an establishment after which the manager should
ensure that all staff who may use them are familiar with the particular MAR used at that home.

      21.2.2 HAND W RITTEN RECORDING DOCUMENTS.

The medication documents (Appendix 11) consist of a profile card and a recording card. There are
additional continuation slips for the recording cards. An alternative document which can be used
for hand written record is a blank Medical Administration Record (MAR) chart similar to those
which pharmacies print. The blank MAR included at Appendix 19 may be photocopied. Blank MAR
charts are particularly useful for respite care. NB: as with other hand written documents of this
kind, all information entered on the chart must be checked by another manager before the
document is used.

21.2.2.1            PROFILE CARD

The PROFILE CARD contains a list of all medicines held for the service user, whether or not they
are currently being administered, and also provides a record of medicines received and the surplus
destroyed. The PROFILE CARD is identically printed on the reverse so when one side is complete
it may be used on the reverse.

21.2.2.2            RECORDING CARD

The RECORDING CARD is used solely for recording the giving of a medicine. It contains a list of
the medicines, the dose and frequency of administration. There is a two-week grid labelled M to S
(Monday to Sunday) for records to be made of each dose given.




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21.3 PROCEDURE FOR COMPLETING HAND WRITTEN DOCUMENTS FOR EACH
     SERVICE USER


      21.3.1 RAISE A MEDICATION PROFILE CARD AND A RECORDING CARD.

These two cards should be displayed in a flip-up “Kardex-type” file (eg Visicard book). After
completing details such as NAME, DATE OF BIRTH, DOCTOR etc, the PROFILE CARD is
inserted in the upper flap of the file and the RECORDING CARD is inserted immediately below it in
the lower flap so that both cards are viewed together. Ensure that the name appearing on the two
cards and on identification photographs will be the name appearing on dispensed medicines. Take
care NOT to use “nick names” or familiar names on one and full names on another. This could
cause confusion if a relief member of staff is administering medicines. Particular care must be
taken if there are service users at an establishment who have the same or similar names.

      21.3.2 COMPLETING A PROFILE CARD

     a. On the PROFILE CARD (upper card) write in the left hand column the NAME and
        STRENGTH of the first medicine that has been prescribed for the service user. The order
        that you write the medicines is not critical but it is more logical to start with any medicines
        that are to be administered only in the morning and then to progress to those taken twice,
        three or four times daily, and finally those taken just at bed-time. Include ALL medicines,
        even if they are being self-administered by the service user.

     b. Write the DOSE and FREQUENCY of administration in the next column, followed by
                           )
        placing a tick (�� in the TIME OF DOSE column. The two blank squares may be used if
        additional or different times of administration are required.

     c. Continue in this way until all the medicines are entered.

     d. Sign and date the completed profile card. The card must then be checked by another
        designated person who must also sign and date it.

      21.3.3 COMPLETING THE RECORDING CARD

Now complete the RECORDING CARD by:

     1. Writing the same medicines names and strengths in the left hand column.

     2. In the DOSE column write the number of dose units to be given, for example “ONE TAB” or
        “TWO TABS”. If the medicine is a liquid state the amount to be given in a single dose, for
        example “5 ml” or “10 ml”.

                       )
     3. Place a tick (�� in the FREQUENCY/TIME column to specify the time when the dose(s) is
        to be given.

     4. Write in the WEEK BEGINNING dates in the two columns provided.



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     5. Sign and date the recording card. The card must then be checked by another designated
        person who must also sign and date it.

The medication documents are now ready for use. The procedure for administering medicines
which is printed on the reverse of every RECORDING CARD should be carefully followed.


                  Please note that after two weeks the RECORDING CARD is finished. A
                  new RECORDING CARD should then be raised.

                  Alternatively, you may attach a gummed continuation slip over the
                  Monday to Sunday recording grid. Up to six sheets may be attached in
                  this way, which allows for a maximum of 14 weeks recording.

                  DO NOT ATTACH MORE THAN 6 SHEETS BECAUSE THEY BEGIN TO
                  DETACH AND THE RECORD WILL THEREFORE BE LOST.




      21.3.4 RECORDS OF MEDICINES RECEIVED AND DESTROYED

The right-hand side of the PROFILE CARD is used to keep records of medicines received and
destroyed. When a medicine is obtained you should enter the date and quantity received. This
section of the record will last for 6 months if you are requesting repeat prescriptions on a 28 day
basis.

If a medicine is discontinued or the service user leaves the home or dies, return the medicines to
the community pharmacist for destruction. The medicines to be returned to the pharmacy must be
listed in the drugs returns book which must be signed and dated by the responsible person making
the entry. A signature must be obtained from the pharmacy to acknowledge receipt of the returned
drugs.

Visiting GPs should be encouraged to place their initials in the box provided to signify any
alteration or discontinuation of medication. In order to do this, staff should ensure that the
appropriate documents are readily available at the time of consultation.

      21.3.5 CONTROLLED DRUGS

Detailed instructions for the records required for Controlled Drugs in addition to those described
above are to be found in Section B6.




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22 INFORMATION AND TRAINING

22.1 GENERAL INFORMATION

In response to the CSCI report „Handled with Care‟ (February 2006) there is to be a major review
of the training given to any members of care staff who may be involved in the administration of
medicines. A programme of training will be developed to ensure that appropriate training is given
to care staff to ensure that they are trained and competent to perform any tasks required for the
administration of medicines. Managers of establishments will be responsible for ensuring that staff
are trained and that training records are kept at each establishment.

22.2 INVOLVEMENT OF COMMUNITY PHARMACISTS

Every home and hostel requires day-to-day professional support from a pharmacist in order to
ensure that medicines prescribed or purchased for service users are used safely and
effectively. Advice is required on the safe custody, storage, administration and destruction of
medicines. Assistance may also be required in obtaining appropriate review of individual
prescriptions. The community pharmacist can assist staff on both accounts.

Community pharmacists are obliged to keep „patient medication records‟ (PMRs) of all
prescriptions dispensed for patients over the age of 60 yrs and for those on long-term
medication. In practice, records are kept of all prescriptions dispensed, (unless a patient
requests otherwise.) The records held are not duplicates of the patient‟s medical records but of
the prescription items dispensed and in some instances of medicines purchased by patients.
Reference to these records, enable the pharmacist to give valuable advice and to respond to
queries regarding medication.

Payment is available from the Primary Care Trust for the community pharmacist to make a
number of advisory visits to the home each year. The community pharmacist is required by the
Primary Care Trust to establish an agreement with the Team Manager of the Home and to
keep records of visits made and of the advice given. The visits should be at regular intervals.
An example of a model form of agreement is given in Appendix 3.

Ideally this advice should be arranged with the pharmacist who regularly supplies the
establishment. However, should the supplying pharmacist not be able or willing to provide
such advice, another suitably qualified community pharmacist should be appointed.

Should the home have reason to terminate this agreement, one month‟s notice must be given
in writing to both the pharmacist and the Primary Care Trust.

Community pharmacists may be eligible for the payment of fees by the Primary Care Trust in
order to provide training of care staff on the safe and effective use of all medicines and
appliances within the residential home. (Please note that not all Primary Care Trusts are able
to pay for such training.)




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        22.2.1 ADVICE ON INDIVIDUAL MEDICINES

The community pharmacist is always available to provide advice on medicines. It is important that
the caring professions who are involved with medication in residential homes meet frequently to
discuss the effective use of medicines.




        22.2.2 ADVICE ON MEDICATION PROCEDURES

Although medication procedures in Northamptonshire County Council residential establishments
are governed by this Medicines Code, the local community pharmacist can advise as to the
interpretation and practical application of the guidance that this code provides. The Primary Care
Trust Pharmacist Adviser is available to provide support to the community pharmacist when it is
required. All community pharmacies supplying medicines to Northamptonshire Social Care‟s
Residential establishments will be provided with a copy of the Medicines Code and, where
required, copies will be made available to community pharmacies outside Northamptonshire.

If independent sector homes agree to accept and implement the Northamptonshire Medicines
Code, copies of the code will be provided to the pharmacies supplying them.

        22.2.3 MEDICINES INFORMATION

Each establishment should have reference sources available which allow managers to learn about
medicines they are administering.

   I.     A recent edition of the British National Formulary (BNF) which is published twice a year in
          March and September should always be on hand as a comprehensive and official reference
          book. This can be obtained by ordering from any bookseller or direct from The
          Pharmaceutical Press, PO Box 151, Wallingford, Oxon, OX10 8QU, tel. 01491 829 272.
          The current price is £16.00 plus p&p.

  II.     In addition, a reference source for medicines used in the speciality of the home may be
          helpful.

 III.     Many find one of the A to Z type paperbacks on general medicines provide a useful
          reference for those carers who have no formal nurse training.

 IV.      Every establishment should have an up-to-date copy of the Royal Pharmaceutical
          Society publication „The Administration and Control of Medicines in Care Homes and
          Children‟s Services‟ (last published Dec 2003). This may be obtained, as an A5
          booklet, from the Royal Pharmaceutical Society, 1, Lambeth High Street, London SE1
          7JN, Tel. 0207 572 2409, price £6.00 plus p&p. Alternatively the document can be
          down-loaded and printed off from the RPSGB website using the following address:-
          www.rpsgb.org.uk/pdfs/adminmedguid.pdf




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  V.      The community pharmacy will send patient information leaflets (PILs) with the medicine
          deliveries. These contain a wealth of information. A simple way to file these
          alphabetically, so they can be accessed easily, is in a ring binder using clear polythene
          pockets.



23 WEBSITE ADDRESS FOR THIS POLICY

                    Policy Library



24 NOTES



25 ACKNOWLEDGEMENTS

Derbyshire County Council in producing the original version of this policy and procedural
document.




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26 GLOSSARY



Administration                          In the context of administering a medicine, the word administer is
                                        used to mean that a service user has been offered a medicine. The
                                        record of administration either shows that a medicine has been
                                        swallowed, applied or refused, or that a service user is absent.


Medication                              An individual record of medication administered, including household
Administration Record                   remedies.
(MAR)


Compliance                              Understanding, consent and co-operation of the service user in taking
                                        their medicine to ensure maximum benefit from the medicine.


Compliance Aid                          A container designed for service users to improve compliance with
                                        solid dosage form medication such as tablets and capsules. A
                                        compliance aid may contain more than one different type of medicine
                                        to be administered at various times of the day, eg breakfast, lunch,
                                        tea-time and bed-time (eg Medidose wallet).


Community Pharmacist                    The pharmacist who dispenses medicines for service users in a
                                        home.


Community Pharmacy                      The Primary Care Trust Pharmacist who provides pharmaceutical
Adviser                                 advice and information to the Older Adults Department.


Designated Officer                      A senior member of staff with overall responsibility for medication
                                        within the home, including the implementation of the Medicines Code.
                                        This person would usually be the Team Manager of the
                                        establishment, but need not necessarily be so.


FP.10 Prescription                      A National Health Service prescription.


Household Remedy                        A product which may be purchased to relieve the symptoms of a
                                        minor self-limiting condition.




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Medicines                               Drugs and other preparations for internal or external use which are
                                        provided to treat service users. This includes tablets, capsules,
                                        powders, oral liquids, substances applied other than by mouth (eg
                                        lotions, injections, infusions, irrigations, ointments, eye/ear/nose
                                        drops, medicated dressings) and certain substances not used for
                                        direct treatment, such as reagents for making diagnostic tests.


Medicines Book                          A register in which all medicines ordered and received should be
                                        entered.


Medication                              A broad term used to describe involvement with medicines




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27 APPENDICES




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28 APPENDIX 1

28.1 NATIONAL MINIMUM STANDARDS, STANDARD 9, MEDICATION OUTCOME


Service users, where appropriate, are responsible for their own medication, and are protected by
the home‟s policies and procedures for dealing with medicines.

Standard 9

          The registered person ensures that there is a policy and staff adhere to procedures for the
          receipt, recording, storage, handling, administration and disposal of medicines, and service
          users are able to take responsibility for their own medication if they wish, within a risk
          management framework.

          The service user, following assessment as able to self-administer medication, has a
          lockable space in which to store medication, to which suitably trained, designated care staff
          have access with the service user‟s permission.

          Records are kept of all medicines received, administered and leaving the home or disposed
          of to ensure that there is no mishandling. A record is maintained of current medication for
          each service user (including those self-administering).

          Medicines in the custody of the home are handled according to the requirements of the
          Medicine Act 1968. Guidelines from the Royal Pharmaceutical Society, the requirements of
          the Misuse of Drugs Act 1971 and nursing staff abide by the UKCC Standards for the
          administration of medicines.

          Controlled Drugs administered by staff are stored in a metal cupboard, which complies with
          the Misuse of Drugs (Safe Custody) Regulations 1973.

          Medicines, including controlled drugs, for service users receiving nursing care, are
          administered by a medical practitioner or registered nurse. (Nursing Home)

          In residential care homes, all medicines including Controlled Drugs, (except those for self-
          administration) are administered by designated and appropriately trained staff. The
          administration of Controlled Drugs is witnessed by another designated, appropriately
          trained member of staff. (Residential Home)

          The training for care staff must be accredited and must include:

          Basic knowledge of how medicines are used and how to recognize and deal with problems
          in use.

          The principles behind all aspects of the home‟s policy on medicines handling and records.




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          Receipt, administration and disposal of Controlled Drugs are recorded in a Controlled
          Drugs register. FOI: Public Version 3.0 Northamptonshire County Council

          The registered manager seeks information and advice from a pharmacist regarding
          medicines policies within the home and medicines dispensed for individuals in the home.

          Staff monitor the condition of the service user on medication and call the GP if staff are
          concerned about any change in condition that may be a result of medication, and prompt
          the review of medication on a regular basis.

          When a service user dies, medicines should be retained for a period of seven days in case
          there is a coroner‟s inquest.




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29 APPENDIX 2


29.1 CONTENTS OF THE ROYAL PHARMACEUTICAL SOCIETY DOCUMENT - „„THE
     ADMINISTRATION AND CONTROL OF MEDICINES IN CARE HOMES AND
     CHILDREN‟S SERVICES‟

  Contents                                                                                            DSS Medicine Code Ref


  1                                     Introduction                                                  Section A
                 1.1                    Current Legislation                                           A1
                 1.2                    Children's Residential Settings

  2                                     Policies and Procedures                                       The Code

  3                                     Record Keeping                                                Section D
                 3.1                    Receipt of Medicines                                          B3.3.8
                 3.2                    Administration of Medicines                                   B11
                               3.2.1    Administration by Service User (Self-                         B11.1
                                        Administration)
                               3.2.2    Administration by Staff                                       B11.2
                               3.2.3    Printed Medicines Administration Record (MAR)                 Section D
                                        Charts
                 3.3                    Disposal of Medicines                                         B13
                 3.4                    Pharmacy Record                                               A4.2

  4                                     Medicines Supply                                              B3
                 4.1                    Presentation of Medicines                                     B3.3.2/3/4
                 4.2                    Labelling of Medicines                                        B3.3.5
                 4.3                    European Law; Patient Information Leaflets                    B3.3.10
                 4.4                    NHS Prescriptions                                             B3.1
                 4.5                    Bulk Prescribing                                              N/A
                 4.6                    Emergency Supplies                                            B9
                 4.7                    Prevention of Fraud                                           B3.2.2
                 4.8                    Monitored Dosage Systems                                      B3.3.2
                 4.9                    Compliance Devices                                            B3.3.4
                 4.10                   Signed Orders                                                 N/A
                 4.11                   Private Prescriptions                                         B3.1
                 4.12                   Verbal Orders                                                 B3.3.6
                 4.13                   Facsimile Transmission of Prescriptions                       B9
                 4.14                   Purchase of Non-Prescription Medicines                        B14

  5                                     Storage of medicines                                          B4
                 5.1                    Medicines Security                                            B5
                 5.2                    Cold storage                                                  B4.2.3

  6                                     Administration of Medicines                                   B11
                 6.1                    Service Users Taking Their Own Medicines                      B11.1
                 6.2                    Medicines Administered by Care Staff                          B11.2



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                               6.2.1    Time of Administration                                        B11.3
                               6.2.2    Refusal and Covert Administration                             B11.9
                               6.2.3    Procedure for Medicines Administration                        B11.4/5/6/7
                               6.2.4    Use of Monitored Dosage Systems (MDS)                         B3.3.2
                               6.2.5    Administration of Medicines away from the Care                B12
                                        Home
                               6.2.6    Day Care; Treatment Outside the Home                          B12

  7                                     Disposal of Medicines                                         B13.1/2/3

  8                                     Medicinal Gases
                 8.1                    Storage of Oxygen                                             B11.11

  9                                     Controlled Drugs                                              B6
                 9.1                    Obtaining Controlled Drugs                                    B6.CD3
                 9.2                    Storage of Controlled Drugs                                   B6.CD4
                 9.3                    Administration of Controlled Drugs                            B6.CD5
                 9.4                    Records for Controlled Drugs                                  B6.CD5/CD7
                 9.5                    Disposal of Controlled Drugs                                  B6.CD6
                 9.6                    Handling of Non-Prescribed Controlled Drugs                   B6.CD2
                                        and their Disposal

  10                                    Medicine Information and Pharmaceutical                       A4.2
                                        Advice in Homes
                 10.1                   Hazard Notification and Drug Alerts                           B11.11/A4.2.4
                 10.2                   Adverse Drug Reaction Reporting                               B11.14

  11                                    Training of Care Staff                                        A4.1
  12                                    Regulation of Care Homes
  13                                    Glossary
  14                                    Bibliography
  15                                    Appendix 1




The full document may be downloaded from the website of the Royal Pharmaceutical Society using

www.rpsgb.org.uk/pdfs/adminmedguid.pdf




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30 APPENDIX 3

30.1 MODEL FORM OF AGREEMENT BETWEEN THE TEAM MANAGER AND THE
     COMMUNITY PHARMACIST

ADVICE TO RESIDENTIAL HOMES

Model Form of Agreement

I     ____________________        Manager        *     Person    in     Control*       of
________________________________ Residential Home, which is registered under the
Registered Homes Act Amended 1999, and the Care Standards Act 2000; CSCI Registration No
________________, request (name of pharmacist) _____________________________________

of (name and address of pharmacy) _________________________________________________

to provide advice on the safe keeping and correct administration of drugs supplied to service users
of this Home from __________________ to 31 March 20 __. I understand that records of visits
made and of the nature of advice given will be kept and will be made available to the
__________________________ PCT for inspection and I agree to provide such facilities and co-
operation as may be requested and are necessary for the provision of the service.

I/We (name of pharmacist or pharmacists) ______________________________ of (name and
address of pharmacy) ____________________________________________________________

agree to provide advice on the safe keeping and correct administration of drugs supplied to service
users of _____________________________________________ Home, for the period ending on
31 March 20 __.

The services provided will include:

          An Initial Assessment

_____ visits each year (number set by PCT at intervals of approximately ____ months.

          Advice on the safe keeping and correct administration of drugs.

          The keeping of records of visits made and advice given.

          If agreed, one of the visits may be for the purpose of staff training.

This agreement may be terminated by one month’s notice in writing given by either party to the
other and to the _________________________ Primary Care Trust.

Number of registered places at __________________ (date) _________________

Signed _____________________ (date) __________________

Manager/Person in Control *



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_____________________ (date) __________________

Pharmacist

* Delete as appropriate




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31 APPENDIX 4

31.1 SUGGESTED SYSTEM FOR EXAMINING AND IDENTIFYING                                                   MEDICINES
     BROUGHT INTO AN ESTABLISHMENT BY A SERVI CE USER

Service users often arrive at an establishment with a large collection of medicines many of which
will be out of date, redundant or contra-indicated for their condition or likely to interact with their
current prescribed medication. It is therefore necessary to urgently sort out the regular prescribed
medicines. The others should be put into a separate bag and not administered until or unless it is
established that they can be given safely. It must, however, be remembered that any such
medicines are the property of the service user and must not be disposed of without their
permission.

The following system is suggested as a means of sorting out a mixed bag of medicines in order to
identify the regular prescribed medicine needed by the service user. The list is long because it
covers all eventualities. The point of the exercise is to isolate from a large quantity of medicines
those which are currently prescribed and actually needed by the service user on a daily basis.

Identify all non-prescription medicines, (items purchased over the counter) and put into a separate
bag.

Examine the dispensed medicines, check the service user‟s name on the labels and remove any
medicines belonging to another person. (It does happen!)

Examine any compliance device brought in. Compliance aids which are fully and recently labelled
by a pharmacy and are sealed and tamper evident (that is to say that it would be obvious if
tablets had been removed from a pocket because the foil was punctured) eg Venalink, may be
used to administer the tablets as set out in the device. Care staff must not administer medicines
which have been put into an unsealed compliance devise, such as a Medidose, by family or
friends of a service user. Some pharmacies dispense medicines into Medidose and other
unsealable devices , care staff should not administer medicines from these devices because the
tablets could have been moved from one pocket to another. Put any discards into a second bag.

Examine the other dispensed medicines and check that the name on each foil strip of tablets in
each box matches the tablets described on the label. Put any discards into the second bag.

Examine bottles of tablets and capsules. Remember that the contents of bottles could be swapped
around. If any contain a mixture of tablets and/or capsules, put these into the second bag. Now
check, if possible, that each bottle contains the tablets or capsules described on the label. Some
tablets and capsules carry an identifiable code. Reference to the British National Formulary (BNF)
may be helpful, however, many small white tablets are impossible to positively identify. If in doubt,
remove bottles of tablets and capsules, put into the second bag.

Be alert for the possibility of Controlled Drugs being among the medicines brought in. If you are not
sure of the legal category of a drug, check it in the BNF. Any CDs received must be entered into
the CD Register and stored in the CD cabinet, even if they are out of date.



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Identify any items which require cold storage, eg insulin and some eye drops, check that they are
recently dispensed, list them, then store in the medicines fridge.

Examine the remaining medicines for date of dispensing, quantity and dose. Use this information to
decide if the medicine is currently being taken. You may need to refer to the BNF to make this
decision. Separate out any medicines dispensed more than six months ago, put these in the
second bag.

If any written or printed medicines‟ information has been received, refer to it, checking first that it is
recent enough to refer to current medication. Remember that lists of repeat medicines from the
surgery may contain information going back a long time. See if the dispensed medicines you have
identified as current medication are listed on the printed information.

Reference could now be made to the information in the BNF to gain some insight into the medical
condition of the service user, do not, however, presume to make medical judgments, just get a feel
for the situation.

At this point, if the service user is not confused, discuss with him/her which regular medicines are
taken daily. This is just to get a service user perspective. Be alert to the fact, however, that many
service users do not take their medication as prescribed. A relative or carer may also be able to
add some information.

At this point it should be possible to make a decision about which medicines, if any, can be given
until details can be confirmed with the service user‟s GP. Keep the medicines given to a minimum.
List the medicines and doses etc on a MAR or Recording Chart. Store the medicines with other
medication for administration by staff.

Store discarded or reserved medicines safely until it is decided what to do with them.




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32 APPENDIX 5


32.1 KEY POINTS ON CONSENT: THE LAW IN ENGLAND

When do we need consent from Service Users?
     1. Before you examine, treat or care for competent adults you must obtain their consent.

     2. Adults are always assumed to be competent unless demonstrated otherwise. If you have
        any doubts about their competence, the question to ask is “can this person understand and
        weigh up the information needed to make this decision?” +Unexpected decisions do not
        prove that the person is incompetent, but may indicate a need for further information or
        explanation.

     3. People may be competent to make some decisions about their care, even if they are not
        competent to make others.

     4. Giving and obtaining consent is usually a process, not a one-off-event. People change their
        minds and withdraw consent at any time. If there is any doubt, you should always check
        that the person still consents to your caring for them.

Can children consent for themselves?
     5. Before caring for a child, you must also seek consent. Young people aged 16 and 17 are
        presumed to have the competence to give consent for themselves. Younger children who
        understand fully what is involved can also give consent (although their parents will ideally
        be involved). In other cases, someone with parental responsibility must give consent on the
        child‟s behalf, unless they cannot be reached in an emergency. If a competent child
        consents to care, a parent cannot over-ride that consent. Legally, a parent can consent if a
        competent child refuses, but it is likely that taking such a serious step will be rare.

Who is the right person to seek consent?

     6. It is always best for the person planning an individual‟s care to seek that individual‟s
        consent.

What information should be provided?

     7. People need sufficient information before they can decide whether to give their consent; for
        example information about the care professionals open to them, and any alternative
        options. If the person is not offered as much information as they reasonably need to make
        their decision, and in a form they can understand, their consent may not be valid.



Is the person’s consent voluntary?




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     8. Consent must be given voluntarily: not under any form of duress or undue influence from
        health or social care professionals, family or friends.

Does it matter how the patient gives consent?

     9. No: consent can be written, oral or non-verbal. A signature on a consent form does not
        itself prove the consent is valid – the point of the form is to record the person‟s decision,
        and also increasingly the discussions that have taken place.

Refusals

     10. Competent adults are entitled to refuse care, even where it would clearly benefit their health
         and well-being. The only exception to this rule is where treatment is for a mental health
         disorder and the person is detained under the Mental Health Act 1983. A competent
         pregnant woman may refuse care, even if this would be detrimental to the foetus.

Adults who are not competent to give consent

     11. No-one can give consent on behalf of an incompetent adult. However, you may still care for
         that person if the care would be in their best interests. „Best interests‟ go far wider than best
         medical interests, to include factors such as the wishes and beliefs of the individual when
         competent, their current wishes, their general well-being and their spiritual and religious
         welfare. People close to the individual may be able to give you information on some of
         these factors. Where the individual has never been competent, relatives, carers and friends
         may be best placed to advise on the person‟s needs and preferences.

     12. If an incompetent person has clearly indicated in the past, while competent, that they would
         refuse treatment in certain circumstances (an „advance refusal‟), and those circumstances
         arise, you must abide by that refusal.

This summary has been adapted from „12 key points on consent: the law in England‟, produced by
the Department of Health March 2001.

This summary cannot cover all situations. For more detail, consult the Reference guide to consent
for examination or treatment, available from the NHS Response Line 0541 555 455 and at
www.doh.gov.uk/consent.




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33 APPENDIX 6

33.1 RISK ASSESSMENT FORM FOR SERVICE USERS WISHING TO SELF-
     ADMINISTER MEDICINES

Medication Risk Assessment and Details of Arrangements for Service Users Who
Wish to Administer their Own Medicines

  Part A The Risk Assessment A risk assessment is designed to establish if a service
  user is able to take control of all or some of their own medicines and if any help or
  special arrangements may be needed in order to allow them to do so.

  Name of Establishment


  Name of manager conducting this assessment


  Name of Service User                                                                                Date of birth


  Date of assessment

  Current Medication                                                                                  Dose

  Service User's Knowledge of Medication – List each of the medicines taken; does the
  service user understand the need for each of these medicines and the importance of
  taking them at the correct time?




  Physical ability - Is the service user able to :




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                                                                                         Yes          No



  Read labels
  Open containers
  Pick up tablets and capsules
  Use eye drops
  Use ear drops
  Apply ointments
  Service User's mental capacity- Is the service user confused or has a learning disability,,
  may they need reminding to take medicines?




  Secure storage - Is secure storage available, is the service user aware of the importance of
  secure storage at all times?




  Disposal arrangements discussed - Does the service user understand that ALL unused
  medicines MUST be returned to staff for disposal?




  Arrangements for new supplies - Would these to be ordered by the service user or the
  staff? Explain that all new supplies must be checked in and recorded on a MAR.




Outcome of this Assessment

The outcome of this assessment is that ______________________________________ will/will not
(delete as appropriate) take control of his/her own medicines.




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  Part B Details of the Arrangements.
  If the service user is to control and self administer medicines, details of the
  arrangements and any help needed must be entered below and filed in the care plan.

  Will the service user order his/her own                                     Yes/No
  medicines?
  Where will medicines be kept?                                               Details


  List below all medicines to be self-administered                            Partial self-administration.
  by the service user.                                                        List below medicines to be
  NB this list must be updated as necessary.                                  administered by care home staff.




  Will the service user need reminding to take                                Yes / No
  medicines?                                                                  How will this be done?

  Are there any special requirements regarding                                Details
  medicine containers? Eg plain tops on bottles,
  compliance aid?

  Is it necessary to inform pharmacy of                                       Yes / No
  requirements?                                                               Who will do this?

  Number of days supply to be given to service                                7 days / 28 days
  user.

  Record of persons involved in this assessment, including GP or family, if appropriate.
  Name of manager                                 Signature

  Name (status)                                                             Signature

  Name (status)                                                             Signature




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  Service User's Statement:- I agree to the conditions laid down by this residential establishment
  that I will keep all medicines secure in the locked drawer/cupboard in my room (or on my
  person) and I will return unused medicines for safe disposal. I understand that the staff are
  required to make adequate recording and monitoring arrangements of my medication, and I will
  co-operate in these arrangements.

  Name of service user                                                       Signature

  Date of Assessment                                                         Date for Review




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34 APPENDIX 7

34.1 DECLARATION OF SELF-CUSTODY OF MEDICINES (FORM SS/159)

                                                                                                      FORM SS/159
NORTHAMPTONSHIRE COUNTY COUNCIL
                                                                                        One copy to be retained by the
                                                                             Service User and one by the Establishment

DECLARATION OF SELF-CUSTODY OF MEDICINES


I confirm that the choices available to me regarding safekeeping and taking of medicines
prescribed by my doctor while I am at ………………………………………………………
(name of establishment) have been explained to me, and that I wish my medicines to be dealt with
in the following manner:


* I wish to retain possession of my own medicines, and undertake to keep them securely at all
times, and abide by the instructions on the label of the container. I undertake to notify the staff of
the establishment of any losses and when the medicine requires renewal.
* I understand that I must not give the medicine to any other service user.
* I request the staff of the establishment to take full charge of my medicine(s).
* Other options:


I understand that I am free to alter my choice at any time after giving suitable notice to the staff of
the establishment.


...................................................................... Signature of Service User


...................................................................... Signature of Witness


Date ..............................................................



*Delete if not applicable.




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35 APPENDIX 8

35.1 SERVICE USERS UNABLE TO MAKE DECLARATION OF SELF-CUSTODY OR
     MEDICINES (FORM SS/160)

                                                                                                                       FORM SS/160
NORTHAMPTONSHIRE COUNTY COUNCIL

SERVICE USERS UNABLE TO MAKE DECLARATION OF SELF-CUSTODY OF MEDICINES

Name of Home: ................................................................................................................................

Name of Service user: .......................................................................................................................

I have examined in full the circumstances of this service user and consider, for the reasons stated
below, that the service user would be unable to retain safe custody of medicines prescribed without
being a danger to him/her self or others, and would be unable to take the responsibility of
administering medicines to him/herself.

I am furthermore of the opinion that this service user is unlikely to be able to make a rational choice
on these matters, or to follow through the consequences of the choice.

I have, therefore, arranged for medicines prescribed for this service user to be retained in the
custody of staff and administered to him/her in accordance with the Medicines Code.

In addition to discussing this matter with the service user on .................................................. (date),

I have discussed this matter with the next of kin, who is:
  ...................................................................................       on ..................................................(date)


Views of next of kin:

I have also discussed this matter with the relevant case-worker or doctor, who is:

  ...................................................................................       on ..................................................(date)

Views of case-worker and/or doctor:

My reasons for the opinion are as follows:

I am aware that, should the service user‟s circumstances change, this declaration should be
reviewed.


  Signature of Team Manager                                                                    Signature of Witness
  (or Team Leader)
  Name in block capital letters                                                                Name in block capital letter




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…………………………………………..                                                                      ………………………………………



………………………………………… .                                                                      ………………………………………



Date:…………………………………….                                                                     ……………………………………..




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36 APPENDIX 9

36.1 SERVICE USERS REQUIRING ADMINSTRATION OF MEDICINES IN FOOD OR
     DRINK BECAUSE OF PROBLEMS WITH SWALLOWING TABLETS OR
     CAPSULES

                                                                                                        FORM SS/161 a
NORTHAMPTONSHIRE COUNTY COUNCIL

SERVICE USERS REQUIRING ADMINSTRATION OF MEDICINES IN FOOD OR DRINK
BECAUSE OF PROBLEMS WITH SWALLOWING TABLETS OR CAPSULES

Name of Home…………………………………………………………………………………..

Name of Service User…………………………………………………………………………..

The above named service user has requested that the prescribed medicines listed below be
given to him/her in food s detailed below because he/she is unable to swallow tablets and
capsules and no liquid forms of the medicine are available. The suitability of these medicines
to be given in this way has been verified by pharmacist (name) ………………………………..

(name of pharmacy) ………………………………………………………………………………….


  Medicine                                                                Method of Administration




(NB The medicine must be mixed with a small quantity of cold food to ensure that the whole
dose is taken by the service user.)

I have requested that the medicines listed above be administered to me in food as detailed
above.


  Signature of Service User ………………………….. Date ……………………………………

This matter has been discussed with the service user‟s next of kin (or representative) who
signs below:

  Name ……………………………………                                          Signature ………………….                     Date ……………………



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This matter has been discussed with the relevant health professional/general practitioner, who
signs below:

  Name ……………………………………                                          Signature ………………….                     Date ……………………



This matter will be reviewed on (enter date) …………………………………..or at an earlier date
if the service user‟s situation or condition changes.

  Name of Manager ………………………. Signature ………………….                                                       Date …………………….




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37 APPENDIX 10

37.1 SERVICE USERS REQUIRING ADMINISTRATION OF MEDICINES IN FOOD OR
     DRINK BECAUSE OF AN IMPAIRED STATE OF MIND

                                                                                                        FORM SS/161 b
NORTHAMPTONSHIRE COUNTY COUNCIL

SERVICE USERS REQUIRING ADMINISTRATION OF MEDICINES IN FOOD OR DRINK
BECAUSE OF AN IMPAIRED STATE OF MIND

Name of Home………………………………………………………………………………..

Name of Service User………………………………………………………………………..

The above named service user is confused and refusing to take medication. He/she is unable
to understand the necessity to take the medicines prescribed for him/her. This matter has
been discussed fully with the service user‟s GP who agrees that it would be in the best
interests of the service user to administer medicine covertly in food or drink in order to
maintain health and well-being.

We are not aware of any previous instructions given by the service user that medicines should
not be given in this manner.

The suitability of these medicines to be given in this way has been verified by pharmacist

(name) ………………………………………pharmacy (name) ……………………………………….


  Name of GP ……………………………. Signature ………………… Date ……………………..


  Medicine                                                                Method of Administration




(NB The medicine must be mixed with a small quantity of cold food to ensure that the whole
dose is taken by the service user.)


This matter has been discussed with the service user‟s next of kin or representative.

  Name …………………………………….. Signature …………………                                                             Date ………………………..


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Views of next of kin or representative:

This matter will be reviewed on (enter date) ……………………………….or at an earlier date if
the service user‟s situation or condition changes.

  Name …………………………………….. Signature …………………                                                             Date ………………………..




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38 APPENDIX 11

38.1 MEDICATION PROFILE CARD AND RECORDING CARD


 MEDICATION PROFILE CARD (top card) AND RECORDING CARD (bottom card)


 SURNAME                                                D.O.B.                                                                          D.O.Ad
 FIRST NAMES                                            SHORT STAY/PERMANENT


 SPECIAL INSTRUCTIONS                                   ALLERGIES TO FOOD AND/OR DRUGS




                                                        DOCTOR




                                                                                                                           Discontinued Surplus
                                                      TIME OF DOSE
   MEDICINE NAME &                                                                     Date and Quantity of Medicine            Destroyed
     STRENGTH          DOSE                                                                     Received

                       FREQUENCY     BREAK    LUNCH     TEA       BED                                                        Date             In
                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC

                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC

                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC

                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC

                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC

                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC

                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC

                                                                                      Date                                                  DR.

                                                                                      Quantity                                              OiC




  Medicine Name and                             WEEK                                               WEEK
       Strength         Dose    FREQ/TIME     BEGINNING       M     T   W    T    F   S      S   BEGINNING      M      T     W      T   F         S   S

                                B




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                                L

                                T

                                N

                                B

                                L

                                T

                                N

                                B

                                L

                                T

                                N

                                B

                                L

                                T

                                N

                                B

                                L

                                T

                                N

                                B

                                L

                                T

                                N

                                                             M    T    W     T    F   S    S          M   T   W   T   F        S   S




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 39 APPENDIX 12

 39.1 MEDICATION UNSUITABLE FOR INCLUSION IN A MONITORED DOSSAGE
      SYSTEM

 MEDICATION UNSUITABLE FOR INCLUSION IN A MONITORED
 DOSAGE SYSTEM
 Not all tablets and capsules are suitable for inclusion in MDS packaging. A list is provided
 below with comments as to the reasons for its unsuitability.

 It should be noted this list is not exhaustive. Unsuitable medication includes effervescent
 tablets, dispersible tablets, buccal tablets, sublingual tablets, significantly hygroscopic
 preparations and solid dose cytotoxic preparations.

 It is ultimately the professional decision of the ‘Pharmacist in Charge’ what medication
 will be included in the MDS packs


Product                                                            Comment
Buccastem tablets                                                  Sensitive to moisture (designed to dissolve in the
                                                                   mouth). May be swallowed
                                                                   inappropriately/accidentally
Cedocard preparations                                              Rapid deterioration in contact with plastic
Cytotoxic preparations                                             Toxic when handled
Diamox sustets                                                     Light sensitive
Dioctyl tablets                                                    Moisture sensitive
Epilim tablets                                                     Extremely hygroscopic, may soften and liquify

Gylceryl trinitrate preparations                                   Loss of potency
Hiprex tablets                                                     Hygroscopic, even on short term storage
Losec                                                              Significantly hygroscopic
Mestinon tablets                                                   Moisture and light sensitive
Minocycline preparations                                           Light sensitive
Nalcrom capsules                                                   Significantly hygroscopic
Natulan capsules                                                   Moisture sensitive
Nolvadex tablets                                                   Photo-degradation possible
One alpha tablets                                                  Significantly hygroscopic
Razoxin                                                            Cytotoxic
Roaccutane capsules                                                Light sensitive
Sinthrome tablets                                                  Light sensitive
Sustamycin capsules                                                Hygroscopic
Temgesic tablets                                                   Sub-lingual, sensitive to moisture


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Treosulfan capsules                                                Moisture sensitive, alkylating agent
Volmax tablets                                                     Performance may be affected if removed from
                                                                   original packaging

 NB: Nifedipine preparations – although light sensitive, this is only minimal and not significant.




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40 APPENDIX 13

40.1      MAXIMUM/MINIMUM FRIDGE TEMPERATURE CHART




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41 APPENDIX 14

41.1 SCHEDULE 2 CONTROLLED DRUGS: GENERIC AND PROPRIETY NAMES

(These drugs must be recorded, administered and stored according to the protocols set out in
Section B 4)

                              Generic Name                                                     Brand Name
  Amfetamines                                                                    Dexidrine, Dexamfetamine tablets
  Amylobartitone                                                                 Amytal tablets, Sodium Amytal capsules
                                                                                 (rare)
  Amylobarbitone & Secobarbital                                                  Tuinal capsules

  Buprenorphine                                                                  Temgesic tabs, Transtec patches,
                                                                                 Subutex tabs(addict use)
  Butobarbital                                                                   Soneryl tablets (rare)
  Cocaine                                                                        substance of abuse, never prescribed
  Codeine Phosphate                                                              all generic, tabs, linctus. Only the
                                                                                 injection is a CD.
  Diamorphine (Heroin)                                                           all generic, tablets & injections
  Fentalyl                                                                       Durogesic patches
  Hydromorphone                                                                  Palladone SR caps
  Meprobamate                                                                    generic tablets (rare)
  Methadone                                                                      all generic, tablets, injection, linctus
                                                                                 (rare), solution(addict use)
  Methylphenidate                                                                Ritalin tablets, Concerta XL tablets,
                                                                                 Equasym tablets, generic
  Morphine                                                                       generic, injection, oral solution &
                                                                                 suppositories; Cyclimorph inj, Oramorph
                                                                                 solution (not CD but treated as a CD),
                                                                                 concentrated solution, unitdose vials,
                                                                                 MST Cont tabs & suspension, MXL
                                                                                 caps, Morcap SR caps, Morphgesic ST
                                                                                 tabs, Sevredol tabs, Zomorph caps
  Oxycodone                                                                      Oxynorm capsules, Oxycontin tablets.
  Pentazocine (rare)                                                             all generic, caps, tabs, injection,
                                                                                 suppositories.
  Pethidine                                                                      generic tabs & injection, also Parmergan
                                                                                 P100 injection (rare)
  Secobarbital                                                                   Seconal Sodium capsules (rare)




Schedule 3 Controlled Drugs



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Temazepam

(Temazepam, because it is likely to be misused, must be stored securely as for full CDs but it is
not necessary to complete CD records for receipt, administration and removal).

Diazepam
Nitrazepam

(The safe custody requirements do not apply to diazepam and nitrazepam, as they are exempt
from these requirements at present, though managers have the option of storing them with full CDs
if they wish to do so. It is not necessary to complete CD records for receipt, administration and
removal for these drugs.




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42 APPENDIX 15

42.1 GUIDELINES FOR USE                              OF      THE       CONTROLLED                DRUGS   REGISTER      IN
     RESIDENTIAL HOMES

Note:- Ward Registers (Controlled Drugs) were distributed to all residential establishments in
December 2002 to be used as Controlled Drugs Registers. More recent registers have the title
Residential Home Controlled Drugs Register. The set-up of the pages in both these registers
is the same, please use the Ward Register before starting the Residential Home Register. In
the case of both registers, it is necessary to make an alteration to the heading of the third
column (Serial No of Requisition) under „Amounts Obtained‟. This should read „Received
by/Witnessed by.‟ Self-adhesive stickers could be used for this purpose.
It is imperative that the Controlled Drugs Register is used in such a way that only ONE service
user and only ONE drug (and only ONE strength of that drug) is entered on a page. The
DRUG INDEX at the front of the Register is used to identify the pages used for each drug and
service user. That is use ONE page per person per drug, when that page is full, go on to the
next blank page.

USING THE CONTROLLED DRUGS REGISTER

Receiving CDs

     1. Refer to the Drug Index to find the page in use for that drug for that service user.
     2. Under „Amounts Obtained‟ count and enter the amount of the drug received, the
     date received and in the third column the initials of the person who receives the CD
     and the initials of a witness, who also checks the amount (Columns 1, 2 and 3).
     3. Add this amount to the amount in the CD Cupboard and enter the new Balance
     Left in Stock in the final column (No 10) on the page.

Administering CDs

     1. Select the appropriate page as above.
     2. Enter the date and time in columns 4 and 5.
     3. Enter the service user‟s name in column 6.
     4. Enter the amount of drug administered in column 7.
     5. Column 8 must be signed by the person administering the drug.
     6. The administration must be witnessed and column 9 signed by the person witnessing
        the administration.
     7. The administrator and witness must then check the balance of the drug left in stock and
        this must be entered in column 10.

Any discrepancies MUST be investigated as soon as possible on that day and an
explanation given.




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43 APPENDIX 16

43.1 MODEL LETTER TO PHARMACIES REQUESTING                                                            IDENTIFICATION     OF
     FRIDGE LINES AND CONTROLLED DRUGS




Dear

You will be aware that Older Adults Department Residential Homes in Northamptonshire are
required to handle the ordering, storage and administration of medicines according to the
policies set out in the Northamptonshire Adults Medicines Code which incorporates the
guidance from the Royal Pharmaceutical Society regarding medicines in residential
establishments.

It would greatly assist us in complying with the Code if you could identify, on delivery of
medicines to this home, items which should be stored in a fridge and also Controlled Drugs
which we are now obliged to store in a Controlled Drugs cabinet and to record in the
Controlled Drugs Register. We are aware that you are not obliged by any terms of contract to
identify these items specifically, but would request that as a matter of good practice they could
be identified by a prominent label on the package in which they are contained.

As these items must be stored appropriately on delivery, please could we ask that either the
delivery person informs us that the delivery contains fridge lines and/or CDs or, that we could
be telephoned with this information before the delivery is made.

Your assistance in these matters will be greatly appreciated,

Yours sincerely




(Team Manager’s name)
Manager of (name of unit)




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44 APPENDIX 17

44.1 MODEL LETTER TO PHARMACIES REQUESTING LABELS                                                     OF    BOTH
     CONTAINERS AND PACKAGING (BOXES) WHERE APPROPRIATE

Dear

You will be aware that HASS Residential Homes in Northamptonshire are required to handle
the ordering, storage and administration of medicines according to the policies set out in the
Northamptonshire Adults Medicines Code which incorporates the guidance from the Royal
Pharmaceutical Society regarding medicines in residential establishments.

It would greatly assist us in complying with the Code if you could in future ensure that
dispensed medicines which are supplied with a container and a package, eg creams,
ointments, eye drops, are labelled both on the container and the package.

We are aware that the Royal Pharmaceutical Society advises labelling containers, that is the
TUBE containing the ointment, as the packet or box is often thrown away. In a residential
home we keep tubes etc in their boxes and our Medicines Code states that both the container
and box should be labelled.

Could you please also attach a small label bearing the name of the service user to eye and ear
drop bottles, you will appreciate the importance of these being administered to the right
service user.

Your assistance in these matters will be greatly appreciated.

Yours sincerely




(Team Manager’s name)
Manager of (Residential Home)




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45 APPENDIX 18

45.1     SUGGESTED LETTER TO CARERS ABOUT MEDICINES INFORMATION AND
        THE PROPER PACKING OF MEDICINES FOR DAY CARE SERVICE

Dear
With reference to………………………………………………..who attends or will be attending
this centre for Day Care, I understand that he/she takes prescribed medicines regularly, some
of which will need to be taken while attending Day Care. I also understand that it will be
necessary for care staff at the centre to administer the medicines.

I am writing to ask for your help to make sure that we have enough information to be able to
administer the medicines correctly. In order to do this we need to know which medicines are to
be given and when they should be given.

Please can you send us an up-to-date medication repeat request form (as supplied by the
doctor‟s surgery for you to order medicines) and inform us if there are any changes to
medication since the date of that form. This will give us the information we need. If you do not
have a spare form, ask the surgery to print one for you.

Please could you also make sure that we have details of the service user‟s doctor so that we
are able to contact him or her if we need to do so.

Please note that staff cannot administer medicines that have not been prescribed by the
doctor, (that is, medicines which have been purchased by or for the service user) unless a
letter is produced from the service user‟s doctor stating that such medicines may be taken.

Please can you also note that care staff are ONLY ABLE to give medicines which are
received at the centre in the original dispensing pack. If the medicine has been removed from
the original pack (the one received from the pharmacy or chemist) and put into another
container, WE WILL NOT BE ABLE TO GIVE IT.

If you are not sure how to do any of these things or if there is anything in this letter that is not
clear, please contact the centre for advice.

Thank you for your help.

Yours sincerely



(Team Manager’s name)




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46 APPENDIX 18a

46.1 SUGGESTED LETTER TO CARERS ABOUT MEDICINES INFORMATION AND
     THE PROPER PACKAGING OF MEDICINES FOR SHORT TERM CARE
     SERVICE USERS

Dear

With reference to …………………………………. who attends or will be attending this home for
short term/respite care., I understand that he/she takes prescribed medicines regularly. I also
understand that it may be necessary for the staff at the home to administer the medicines.

I am writing to ask for your help to make sure that we have enough information to be able to
administer the medicines correctly. In order to do this we need to know which medicines are to be
given and when they should be given.

Please could you send us an up to date medication repeat request form (as supplied by the
Doctor‟s surgery for you to order medicines) and inform us if there are any changes to the
medication since the date on that form. This will give us the information we need. If you do not
have a spare form, ask the surgery to print you one.

Please note that staff can not administer medicines that have not been prescribed by the Doctor,
(that is, medicines which have been purchased by or for the service user) unless a letter is
produced from the service user‟s Doctor stating that such medicines may be taken.

Please can you also note that we are only able to give medicines which are received at the home
in the original dispensing pack which must be labelled with the pharmacy label. If the medicine has
been removed from the original pack (the one received from the pharmacy or chemist) and put into
another container, we will not be able to give it. Also we will not be able to administer medication
that has packaging that has been written on ie the instructions MUST be printed by the dispensing
chemist or pharmacy.

If you are not sure how to do any of these things or if there is anything in this letter that is not clear,
please contact the home for advice.

Thank you for your help.

Yours sincerely

(Team Manager’s name)
Manager (name of Residential Home)

Northamptonshire County Council complies with the Data Protection Act 1998 and values the
importance of your information and will safeguard it and keep it accurate. Wherever possible, we
obtain your consent before sharing your information so we can ensure you get the most
appropriate care and support in the right circumstances.




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47 APPENDIX 19

47.1 SERVICE USER MEDICAL ADMINISTRATION RECORD (MAR)

N ame:                                                                         Ad dres s:
Do B:

Allergies :
Do cto r:
Start Date:                                               Perio d:                                             Start Day:
                                                          w/c                          w/c                     w/c                  w/c


        ME DICATION DET AI LS                Time/ Dose




Quan t.        Re cd .             By                     R etu rned /Des troyed                                            By




Quan t.        Re cd .             By                     R etu rned /Des troyed                                            By




Quan t.        Re cd .             By                     R etu rned /Des troyed                                            By




Quan t.        Re cd .             By                     R etu rned /Des troyed                                            By




Quan t.        Re cd .             By                     R etu rned /Des troyed                                            By


Key:           R: Redused       N: Nausea or Vomiting         H: In Hospital       L : On leav e   D : D est roy ed     D/C: Discontinued




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48 APPENDIX 20

48.1 EXAMPLE OF A HOSPITAL ADMISSION FORMS :COPY IN GREEN PAPER

  Name and Address of Establishment:                                                  Tel No:


  Name of Service User:

  Service User’s Home Address (name of contact person):


  Service User’s Telephone Number:

  Date of Birth:                                                                                      Age:

  GP:                                                                                 Tel No:

  Next of Kin:                                                                        Tel No:

  Medication (including strength)                                                                         Dose

  Please include a photocopy of current MAR sheet

  Allergies:


  Past Medical History:


  Moving and Handling Issues:



  Tissue Viability:



  Any Other Problems:




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49 APPENDIX 21

49.1 NORTHAMPTONSHIRE COUNTY COUNCIL ADULTS HOUSEHOLD REMEDIES
     POLICY

The Use of Household Remedies in Residential Establishments

This Policy defines the requirements and arrangements for the obtaining and for the use of
Household Remedies, or „over-the counter‟ non-prescription medicines in establishments
owned and run by Northamptonshire Older Adults Department.

     1. „Household Remedies‟ are medicinal products that may be purchased „over-the-counter‟
         from pharmacies, or other retail outlets, without the need for a prescription. These will
         include mild analgesics (pain killers) and cough mixtures.


     2. The establishment may hold small quantities of certain Household Remedies for
         emergency purposes or for the treatment of minor, self limiting conditions. These may
         be purchased, usually from the regularly used pharmacy, through normal purchasing
         procedures.


     3. A list should be prepared with due consideration (and updated regularly) of the
         Household Remedies stocked at each establishment. This should be kept in a suitable
         place known to all who may need to refer to it. (eg Drug File or Medicines Code). A
         suggested list may be found at Appendix 22


     4. Household Remedies must not be used for more than three days without reference to
         the service user‟s GP.


     5. All administration of Household Remedies must be recorded on the MAR or regular
         drug administration card.


     6. Household Remedies should be stored in the treatment room, which is kept locked when
         not in use, preferably in a separate medicines cupboard or if not available, in a
         separate, identified, section of a medicines cupboard or trolley.


     7. For each service user, refer to the supplying pharmacist to establish which of the
         medicines, listed on the Household Remedies list, are compatible with the service
         user‟s prescribed medicines and may be taken without reference to the GP. This
         information must be kept with the service user‟s care plan. This must be repeated
         following any changes in prescribed medication.




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     8. Before any Household Remedy is administered to a service user, the manager on duty
         must refer to these notes for any possible contra-indications. If in doubt contact the
         regular pharmacy, the GP or if out of hours, NHS Direct.


The contents of the Household Remedies cupboard should be date checked every six months
and short dated items replaced. The date of opening should be marked on liquid medicines
which should be replaced six months after opening.




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50 APPENDIX 22

50.1 LIST OF HOUSEHOLD REMEDIES




                                        Suggested list of Household Remedies



                     Condition                                   Suggested Remedy                     Chart Number
  Mild pain                                               Paracetamol 500mg tablets                        1
  Indigestion                                             Magnesium Trisilicate/                           2
                                                          Gaviscon/Maalox?
  Cough                                                   Simple Linctus Sugar Free /                      3
  Sore throat                                             Glycerin Lemon & Honey                           4
                                                          pastilles AND suitable sugar
                                                          free pastilles for diabetic and
                                                          obese service users. Soluble
                                                          paracetamol tablets
  Sore mouth                                              Bonjela, Chlorhexidine                           5
                                                          mouthwash (Corsodyl)
  Constipation                                            Senna tablets                                    6
  Diarrhoea                                               Oral rehydration sachets, eg                     7
                                                          Dioralyte
  Mild skin problems                                      Emulsifying ointment                             8
                                                          (preferably in a tube),
                                                          Sudocrem, Vaseline, Sun
                                                          screen (min SPF 20) lotion and
                                                          cream, Waspeze.
  Minor wounds, bites, stings, burns                      Savlon Antiseptic Spray,                         9
  and scalds                                              Calamine lotion and cream,
                                                          Wasp-Ese Spray




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51 APPENDIX 23

51.1      FLOW CHARTS FOR HOUSEHOLD REMEDIES

Treatment of Minor Ailments with Household Remedies                                                                                        CHART 1
Guidance flowchart for use when service user has MILD PLAN only
All cases of acute or severe pain must be referred


                                                                           Yes to either
Is there any doubt that the symptoms are caused by
                                                                                            Contact GP or NHS Direct
indigestion or is the service user generally unwell?
                                                                                                                                                        Box 1
                                                                                                                                             Some medicines that commonly
                                                                                                                                                  cause indigestion
                                     No
                                                                                                                                           • Anti-inflammatory medicines eg
                                                                                                                                           aspirin, ibuprofen, diclofenac, naproxen
Is service user taking any medication associated with                                                                                      • Oral corticosteroids eg prednisolone
                                                                               Yes          Contact pharmacist or GP
causing indigestion? Check information leaflets and
                                                                                            and proceed as below
see Box1



                                     No

                                                                                                                                                           Box 2
                                                                                            Contact pharmacist for advice or avoid                    Lifestyle Advice
Is service user taking any medication which carries a                        Yes
warning to avoid antacids or indigestion remedies?                                          giving indigestion medicine within two hours
                                                                                            either side of affected medication             • Eat small regular meals. Chew food
(Check label)                                                                                                                              well • Avoid bending or stooping
                                                                                                                                           during and after meals
                                     No
                                                                                                                                           • Cut down or stop smoking, alcohol,
                                                                                                                                           caffeine (contained in coffee, cola
                                                                                                                                           drinks, tea and some pain killers).
                                                                                                                                           • Avoid „culprit‟ foods eg curries
                                                                                            Give Gaviscon* after meals and at bedtime.     • Avoid clothing which is tight around
Do symptoms involve burning sensation                                        Yes
                                                                                            Give lifestyle advice (see Box 2)              the waist
rising up towards throat?



                                      No



Give simple indigestion mixture eg Co-magaldrox*                                           Contact GP or NHS direct if symptoms are
(Maalox)* mixture and lifestyle advice (See Box 2)                                         not relieved by treatment                             * = Household Remedy

                                                                                                                                                                                      R

Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.


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Treatment of Minor Ailments with Household Remedies                                                                          CHART 1
Guidance flowchart for use when service user has MILD PLAN only
All cases of acute or severe pain must be referred


                                                                                                      Paracetamol* may be given provided that the
                                                                                                      maximum dose of EIGHT tablets in 24 hours is
                 Has service user taken any                                                           not exceeded and that it is at least FOUR
                 medication containing paracetamol                                                    HOURS since the last dose. REMEMBER that
                                                                                               Yes
                 during last 24 hours?                                                                paracetamol is an ingredient of medicines such
                 (Remember to include any purchased                                                   as co-codamol (includes Kapake, Solpadol &
                 products especially cough & cold                                                     Remedeine) co-dydramol, co-proxamol as well
                 remedies)                                                                            as many products purchased over the counter
                                                                                                      such as cough & cold remedies (check labels
                                                          NO                                          carefully)


                   Give paracetamol tablets 500mg*

           For adults give ONE or TWO tablets per dose and
                                                                                                                    * = Household remedy
           repeat if necessary every FOUR to SIX hours
           NO MORE THAN EIGHT TABLETS MUST
           BE TAKEN IN 24 HOURS For children under
           12 years follow dose instructions on label


Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.



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Treatment of Minor Ailments with Household Remedies                                                                                                  CHART 2
Guidance flowchart for use when service user has an INDIGESTION AND/OR HEARTBURN

Indigestion is experienced as discomfort, or a burning pain in the central chest region. When this burning rises up towards the throat it is referred to as heartburn.


                                                                            Yes to either
Is there any doubt that the symptoms are caused by                                           Contact GP or NHS Direct
indigestion or is the service user generally unwell?                                                                                                        Box 1
                                                                                                                                                 Some medicines that commonly
                                                                                                                                                      cause indigestion
                                      No
                                                                                                                                              • Anti-inflammatory medicines eg
                                                                                                                                              aspirin, ibuprofen, diclofenac, naproxen
Is service user taking any medication associated with                                                                                         • Oral corticosteroids eg prednisolone
                                                                                Yes          Contact pharmacist or GP
causing indigestion? Check information leaflets and
                                                                                             and proceed as below
see Box1



                                      No

                                                                                                                                                                Box 2
Is service user taking any medication which carries a                                                                                                      Lifestyle Advice
                                                                              Yes            Contact pharmacist for advice or avoid
warning to avoid antacids or indigestion remedies?
                                                                                             giving indigestion medicine within two hours      • Eat small regular meals. Chew food
(Check label)
                                                                                             either side of affected medication                well • Avoid bending or stooping
                                                                                                                                               during and after meals
                                      No
                                                                                                                                               • Cut down or stop smoking, alcohol,
                                                                                                                                               caffeine (contained in coffee, cola
                                                                                                                                               drinks, tea and some pain killers).
                                                                                                                                               • Avoid „culprit‟ foods eg curries
Do symptoms involve burning sensation rising up                                                                                                • Avoid clothing which is tight around
                                                                              Yes            Give Gaviscon* after meals and at bedtime.
towards throat?                                                                                                                                the waist
                                                                                             Give lifestyle advice (see Box 2)



                                       No



Give simple indigestion mixture eg Co-magaldrox*
(Maalox)* mixture and lifestyle advice (See Box 2)                                          Contact GP or NHS direct if symptoms are
                                                                                            not relieved by treatment                                 * = Household Remedy




Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.

Treatment of Minor Ailments with Household Remedies                                                                                                  CHART 3




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Guidance flowchart for use when service user has a COUGH


   Does Service user have any other symptoms such                                                                Yes
    as shortness of breath, chest pain, wheeziness or                                                                  Contact GP or NHS Direct
                seem generally unwell?

                                                     No
                                                                                                                 Increase use of reliever inhaler (e.g
                                                                                                      Yes     Salbutamol or Terbutaline – usually blue
                         Is service user asthmatic?                                                           in colour) to TWO Doses FOUR times a
                                                                                                              day. Refer to the service user‟s asthma
                                                                                                                 management plan if they have one.
                                                     No


                                                                            Dry, irritating, non productive
                                                                                                                Give Simple Linctus * (preferably
                                  Nature of the cough?
                                                                                                                     sugar free for diabitics)


                                                       Loose and
                                                       productive

                                                                             Clear, white or pale yellow        Give plenty of fluids and Simple
                                  Nature of the phlegm?                                                        Linctus * (preferably sugar free for
                                                                                                                            diabitics)

                                                         Copious, unpleasant, dark coloured,
                                                               rusty or bloodstained
                                                                                                                          * = Household Remedy
                         Contact GP or NHS Direct



Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.



Treatment of Minor Ailments with Household Remedies                                                                           CHART 4
Guidance flowchart for use when service user has a SORE THROAT



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               Is the service user experiencing                                 YES
                                                                                            Contact GP or NHS Direct
               severe difficulty in swallowing?                                                                                          Agranulocytosis

                                                                                                                                  A rare side effect
                                                  No
                                                                                                                                  characterized by fever with
                                                                                                                                  ulceration of the mouth and
          Does the service user take any                                                                                          throat. Examples of
          medication which could cause                                                       Contact Pharmacist or                commonly prescribed
                                                                                  YES                                             medicines which could cause
          agranulocytosis? Check information                                                 NHS Direct
          leaflet(s) for all medicine(s) currently                                                                                Agranulocytosis:
          taken (see Box)                                                                                                         • Carbimazole
                                                                                                                                  • Carbamazepine
                                                  No                                                                              • Spironolactone


               Does service user use a steroid                                  YES
                                                                                               Contact Pharmacist or GP or NHS
                                                                                                                                    * = Household Remedy
               inhaler? (Usually brown colour)                                                 Direct


                                                 No
                                                                                                      Continue with any prescribed paracetamol-containing
                                                                                                      medication up to the prescribed dose. Plain paracetamol
    Is service user taking paracetamol or any                                                         tablets could be substituted with soluble ones which can
                                                                                           YES
    medicines which contains paracetamol?                                                             be gargled before swallowing. Cough & cold remedies are
    (remember to include cough & cold remedies)                                                       not included in the household remedies list and advice
                                                                                                      from a Pharmacist or NHS Direct should be sought before
                                                                                                      continuing with these.
                                                  No
                                                                                                                                   And

 Take ONE or TWO soluble paracetamol tablets*
                                                                                                      Drink plenty of fluids. Warm ones are often more
 dissolved in water every FOUR to SIX hours (no more
                                                                                            And       soothing than cold ones. Suck glycerine honey & lemon
 than EIGHT in 24 hours) and GARGLE BEFORE
                                                                                                      or blackcurrant pastilles* (caution: these are best
 SWALLOWING.
                                                                                                      avoided in diabetics because of the sugar content). Ice
 For children under 12 years follow dose
                                                                                                      cream or cold yoghourt may give relief.
 instructions on label.



Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.




Treatment of Minor Ailments with Household Remedies                                                                                        CHART 5
Guidance flowchart for use when service user has a SORE MOUTH


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Mouth ulcers Uncomplicated mouth ulcers are round or oval and less than 10mm in size (i.e. no larger than the blunt end of a pencil). If they are
larger or if they last for more than 14 days then refer service user to a doctor or dentist otherwise use Bonjela (but NOT under dentures).
Sipping iced water before eating can be useful to relieve discomfort.

Sore/bleeding gums If service user is taking warfarin then refer urgently to GP otherwise refer to dentist and use salt water mouthwashes
(ONE TEASPOONFUL OF SALT IN A PINT OF WARM WATER) or chlorhexidine (eg Corsodyl) mouthwashes twice or three times a day.

Denture rubbing Remove dentures for as long as possible and refer to dentist. NEVER USE BONJELA UNDER DENTURES AS THIS COULD
CAUSE SEVERE GUM DAMAGE.

Sore mouth or tongue could be caused by thrush which is a yeast organism. Thrush often develops as a result of antibiotic treatment, poor denture
hygiene or steroid inhaler use. Oral thrush can be associated with infection of other mucous membranes eg vagina particularly after treatment with
antibiotics. If thrush is suspected then contact a doctor or pharmacist. Dentures should be removed and soaked in a denture sterilising solution
(eg Steradent).

Sores or cracks at corners of the mouth Refer to doctor or pharmacist. Can be associated with poor dental hygiene so dentures should be
removed and soaked in denture sterilising solution (eg Steradent).

Cold sores The service user will usually have experienced these previously and be familiar with treating them. If in doubt contact a pharmacist for
advice. In the mean time it is often useful to exclude air by covering the cold sore with a product such as white petroleum jelly (eg Vaseline).


Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without
contacting the service user’s GP. Ensure the next shift is informed about any household remedies that have been given.

Treatment of Minor Ailments with Household Remedies                                                     CHART 6
Guidance flowchart for use when service user has CONSTIPATION




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  Does the service user show any of
  the following alarm signs?                                                                                                   Table
  • Blood in stools                                                                 Contact GP
                                                                   Yes
  • Severe abdominal pain                                                            or NHS                  Some common drugs which can cause
  • Unintentional weight loss                                                         Direct                 constipation:
  • Associated diarrhoea                                                                                     Indigestion remedies containing
  • Painful and ineffectual straining                                                                        Aluminium or Calcium
                                    No                                                                       Antidiarrhoeals eg loperamide (Arret,
                                                                           Contact GP or Pharmacist and      Imodium) or kaolin & morphine
 Is service user taking any medication                                                                       Antihistamines eg chlorphenamine
                                                                Yes        • Increase fluid intake
 which could cause constipation? See                                                                         (Piriton), promethazine (Phenergan)
                                                                           • Increase dietary fibre
 Table and patient information leaflets.
                                                                           • Increase exercise if possible   Cough suppressants eg codeine &
                                                                                                             pholcodine
                                      No                                                                     Diuretics eg bendroflumethiazide,
    • Increase fluid intake                                                                                  furosemide (if dehydration occurs)
                                                              Effective       Continue advice to prevent     Pain killers containing opiates eg codeine
    • Increase dietary fibre
                                                                              recurrence                     dihydrocodeine, morphine, tramadol
    • Increase exercise if possible
                                                                                                             Verapamil (Securon, Univer)
                                                                                                             Some antidepressants eg
                                      No                                                                     amitriptyline,dosulepin, imipramine
                                                                                                             Some drugs used to treat Parkinson’s
 In addition to above give senna
                                                                                                             disease eg levadopa, benzhexol
 tablets*. ONE or TWO at night as a                                      If constipation continues or
                                                                                                             Antipsychotics eg promazine,
 short term measure.                                                     recurs then fibre products (eg
                                                                                                             prochlorperazine (often use for nausea &
                                                                         ispaghula) or lactulose may be
                                                                                                             vertigo)
                                                                         prescribed by nurse or GP.
                                  Not Effective
                                                                         BECAUSE THEY CAN TAKE
                      Contact GP                                         UP TO 3 DAYS TO WORK IT                     * = Household remedy
                                                                         IS IMPORTANT THAT THEY
                                                                         ARE USED REGULARLY.


Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.

Treatment of Minor Ailments with Household Remedies                                                                  CHART 7
Guidance flowchart for use when service user has DIARRHOEA




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                                                                                                                                     IMPORTANT
                                                                                                                           Staff and service users must
           Are any of the following present?                                                                               exercise rigorous hand hygiene
           • Blood or mucous in stools                                                                                     as diarrhoea can spread
           • A recent history of constipation                                                                              through hand - surface contact
           • The diarrhoea is accompanied by vomiting                                                                      to other service users. Seek
           lasting more than 24hours                                                      Yes         Contact GP or
                                                                                                                           medical advice if more than one
           • The stools are black & tarry                                                             NHS Direct
                                                                                                                           case occurs as this could
           • Severe abdominal pain
                                                                                                                           indicate a serious cause.
           • Drowsiness
           • Confusion


                                                       No                                               Contact pharmacist or NHS Direct AND encourage
                                                                                                        service user to drink plenty of clear fluids such as
            Is service user taking any medication                                                       water or diluted squash. Avoid dairy products such
            which could cause diarrhoea? Common                                              Yes        as milk or cheese. Foods suitable to eat include
            culprits are antibiotics (current or very                                                   bananas, plain boiled rice, stewed apples and
            recent) and laxatives!                                                                      toast with honey or jam but avoid margarine or
                                                                                                        butter.

                                                       No


            Encourage service user to drink plenty of                                                   If the diarrhoea is severe it may be useful to offer
            clear, non-milky fluids such as water or                                                    rehydration solutions* (eg Dioralyte) to drink.
            diluted squash. Avoid dairy products                                                        Such solutions should be prepared following the
            such as milk or cheese. Foods which are                                                     manufacturer‟s instructions and drunk within 1hour
            suitable to eat include bananas, plain                                                      (stored in a refrigerator it may be kept for up to 24
            boiled rice, stewed apples and toast.                                                       hours).




 NB Diabetics must continue taking their insulin and/or oral diabetic
 medication. Oral rehydration solutions eg Dioralyte may upset                                                        * = Household remedy
 blood sugar control therefore test blood or urine sugar frequently.
 Seek advice if necessary.




Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.

                       Treatment of Minor Ailments with Household Remedies                                                                 CHART 8
          Guidance flowchart for use when service user has MINOR SKIN PROBLEMS




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             Disposable gloves must be used when applying any skin preparations
             Dispose of gloves immediately after use and before treating another service user
             Tubes of ointments or creams are preferable to jars as they reduce risk of contamination & degradation of product
             Always use a separate tube/jar for each service user. Never share.


                                 Dry Skin
Dry skin often occurs in the elderly and can lead to problems                                                                 Pressure Areas
(especially of the feet) if left untreated. Emulsifying ointment* is                                  Barrier creams (see incontinence rash box) can be used on
a good moisturiser. It can be used frequently and used as a soap                                      pressure areas but any signs of development of a pressure
substitute. White soft paraffin*(Vaseline) is useful for dry lips.                                    sore must be referred to a district nurse without delay



                                                              Sun protection
This is important even in our country! Some service users may be taking medication which makes their skin more sensitive to sunlight so
check the labels on their medicines. Encourage the use of hats and avoid skin exposure as much as possible. Use a sun screen with a
minimum sun protection factor of 20. Use a spray formulation if it is to be used for more than one service user and either let them spread it
on their own skin or use a new pair of disposable gloves for each serviceuser.


                                                            Incontinence Rash
Incontinence rash can be prevented and treated with a barrier cream. Zinc & Castor oil cream* is an old favourite but may not be available
in tubes. Morhulin* (50G tube) is a similar alternative. Conotrane*, Sudocrem* and Vasogen* creams are also suitable barrier creams all
available in tubes. White Soft Paraffin* (Vaseline) can also be used.




                                            Sweat Rash
This is can be managed by keeping the skin dry using gauze or tissue in areas where the skin                                          * = Household remedy
surfaces touch eg in the groin and under the breasts.



Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been given.


Treatment of Minor Ailments with Household Remedies                                                                               CHART 9
Guidance flowchart for use when service user has BITES, STINGS, BURNS, SCALDS & MINOR WOUNDS




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             Disposable gloves must be used when applying any skin preparations
             Dispose of gloves immediately after use and before treating another service user
             Tubes of ointments or creams are preferable to jars as they reduce risk of contamination & degradation of product
             Always use a separate tube/jar for each service user. Never share.



                                                            Bites & Stings
 • Bites and stings can be treated with calamine lotion* or cream*.
 • A pain killing spray such as Wasp-Eze* may be useful especially on outings.
 Persons known to be allergic to wasp or bee stings must keep their emergency treatment with them at all times.



                                                            Burns and scalds
• Bathe or immerse in cool running water (not ice cold) for at least 20 minutes.
• Don’t apply creams or ointments.
• Try to keep blisters intact.
• Cover with a sterile non-adherent dressing secured if necessary with hypo-allergenic tape. • If the skin is broken check regularly (12
hourly) for signs of infection (redness, inflammation, pus).
Seek medical advice if the burn/scald causes a blister larger than a 50p piece or if there are signs of infection. IF


                                                           Minor wounds
 • Cleanse the wound thoroughly with running tap water to remove any debris.
 • Antiseptics are not generally needed though a chlorhexidine (Savlon) antiseptic spray* can be used if required. • Cover with a
 suitable dressing.
 Seek medical advice for large/severe wounds or if infection develops (redness, inflammation, pus)



                                                                                                                        * = Household remedy


Remember that treatment with household remedies must be recorded on the MAR chart and must be for NO MORE THAN 3 DAYS without contacting the service user’s
GP. Ensure the next shift is informed about any household remedies that have been give




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52 APPENDIX 24

52.1 NORTHAMPTONSHIRE COUNTY COUNCIL, MEDICATION ERROR POLICY

In the event of an error occurring in the administration of a service user‟s medication, the following
procedures should be followed:-

1. Inform the manager on duty. Telephone the service user‟s GP or pharmacy (or if out of hours
NHS Direct) with full details of the incident for a medical judgment of the significance of the
incident.

2. Follow any advice given by the medical professional contacted, try to make sure you have the
person‟s name, in case you need to refer back to them.

3. Enter full details, name of service user, incident, person consulted, advice received, action taken
etc into the Communication Book and the service user‟s log forms.

4. Manager now makes a judgment whether to inform the service user and or next-of-kin. If the
incident occurs during the night and the resident‟s condition is stable, inform the manager on duty
the next day who will inform the service user and/or next-of-kin, if appropriate.

5. Major Errors, (an error which results in death, which results in the service user remaining in
hospital for more than 24 hours or one which renders the service user unconscious), the following
should be informed by telephone as soon as possible:-

a) The Service Manager

b) The Registered Provider, Northamptonshire County Council.

c) The Principal Health and Safety Officer, Northamptonshire County Council.

The above must then be notified officially using a Northamptonshire County Council

Report of Injury or Dangerous Occurrence Form in addition to a Northamptonshire Adult
Department Medication Error Report Form (Appendix 25).

d) The Commission for Social Care Inspection (CSCI) should also be informed using a Regulation
37 Form.

6. Minor Errors (that is those that have resulted in no serious harm to the service user) should be
reported to the Service Manager (or to his or her deputy) within two hours of the discovery of the
error, or early the following morning if the error occurs at night. The Service Manager will filter such
reports and make a decision whether to refer the report on further or not. A written report must be
completed using the form at Appendix 25.




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7. Unresolved Errors (that is, those the outcome of which is unknown) must be reported to the
Service Manager as above and followed up with information about the outcome as soon as this is
known. A written report must be completed using the form at Appendix 25.

8. All reports of errors (major and minor) must be filed under type of error (patient identification
error; dose error etc) and kept for three years. Reports of errors should be examined every six
months (or sooner if necessary) so that common causes of errors may be identified and systems or
procedures changed if necessary.

9. Managers and/or any other care staff involved must write a full and complete statement as soon
as possible after the event, date and sign it. It is very easy to loose sight of exactly what has
happened, even by the next day. The statement(s) must be hand written by the people involved.
Computer produced statements are not acceptable as they can be changed.




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53 APPENDIX 25

53.1 MEDICATION ERROR/NEAR MISS INCIDENT REPORT FORM




  HEALTH AND ADULT SOCIAL SERVICES MEDICATION ERROR/ NEAR MISS INCIDENHT REPORT
                                      FORM


ERRORS

An error in medication administration is defined as any deviation from the prescribed dose. Errors are
defined in three different categories (see below)

For all errors the whole form must be completed.

In all instances the form MUST BE COMPLETED BY HAND by the Manager on duty and any person(s)
involved in administering the medication.


(a) Major Error - is an incident which results in major harm or death, admission to hospital for 24 hrs or
more, or in the service user being rendered unconscious.

Major errors must be reported by telephone to the Service Manager, HSE and Health and Safety Section
immediately, followed by this form. A copy must also be filed at the home and a copy sent to the Planning
and Project Manager at Headquarters

NB In the event of a Major Error, the Service Manager must be notified by telephone at the earliest
opportunity, he/she will then contact Health and Safety Section. If the Service Manager is not available,
Health and Safety Section must be notified by telephone direct. A RIDDOR form must be completed and
sent to the Service Manager, H.S.E. and to Health and Safety Section within 24 hrs of the incident, and a
copy filed under type of error at the home.


(b) Unresolved Error - (The outcome of the incident is at present unknown)

Complete the whole form. A copy must also be filed at the home and a copy sent to the Health and Safety
Section, the Service Manager and Planning and Project Manager at HQ


(c) Minor Error - (The service user has suffered no serious harm)

Complete the whole form. A copy must also be filed at the home and a copy sent to the Health and

Safety Section, the Service Manager and Planning and Project Manager at HQ.


(d) Near Miss Incident - The service user has suffered no serious harm as the error was avoided

A near miss in medication administration is defined as an incident which might have resulted in an error if it




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had not been noted and rectified before the error occurred.

For near miss incidents, sections 1, 2, 3, 11, 12, 13, 17 and 18 ONLY must be completed, A copy must
also be filed at the home and a copy sent to the Health and Safety Section, the Service Manager and
Planning and Project Manager at HQ.


     1.                                        Indicate the level of the error                        Tick below


                        a) Major Error (Incident resulting in major harm or death)


                        b) Unresolved Error (The outcome of the incident is at present
                           unknown)


                        c) Minor Error (The service user has suffered no serious harm)


                        d) Near Miss (The service user has suffered no serious harm as the
                           error was avoided)


     2.            Details of the person completing this form


                   Full Name


                   Job Title


                   Name and Address of unit


                   Telephone number of unit


     3.            Details of medication error or near miss


                   Name of service user:


                   Date and time error occured


                   Date and time error discovered


                   Details of the error- please describe what happened (use an additional sheet if necessary)




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     4.            Pharmacy Name:

                   Telephone number:


     5.            GP Name:

                   Telephone number:


     6.            Name (s) and job descriptions (s) or any other staff involved in the incident:


     7.            Has the service user been informed about the error?                                Y/N

                   If no, state reason


     8.            Has the service user next of kin been informed about the error?                    Y/N

                   If no, state reason


     9.            Who was contacted for advice?


                   GP/Pharmacist/NHS Direct (delete as appropriate)


                   Name of person contacted


                   Telephone number


                   Date and time of contact


                   Details of advice given




     10.           Actions Taken


                   Did you act on this advice?                                                        Y/N


                   Was any medical treatment necessary?                                               Y/N


                   Have you informed your line manager?                                               Y/N




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                   Has the service user been informed of this advice?                                 Y/N


                   Have you (with the service user‟s consent if appropriate) contacted a              Y/N
                   relative or carer about this advice?




                   Does the service user (or relative/carer) wish to take the matter                  Y/N
                   further?


     11.          What type of medication error/near miss incident occurred?                          Tick below


                  Wrong service user


                  Wrong quantity given


                  Wrong strength of medicine administered


                  Wrong form of the medicine


                  Dose omitted


                  Wrong medicine given


                  Medicine out of date


                  Recording error


                  Medicine given at wrong time


                  Other




     12.          Cause of the error/near miss incident                                               Tick below


                  Unclear labelling instructions caused confusion




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                  Wrong service user name


                  Product out of date


                  Interruptions


                  Other cause


     13.          Action taken to prevent a recurrence (Manager to complete)


                  Review of systems procedures                                                        Y/N


                  If yes, state how this was done


                  Employee Training                                                                   Y/N


                  If yes, state what has been done


                                                                                                      Tick below


                  Medication review requested. By when?

                  Request GP/pharmacy to improve labelling instructions


                  Request alternative packaging


                  Photos of service users (NB This should be in place)


                  Other




     14.          Has Health and Safety Section been informed (in the case of a                       Y/N
                  Major error)


     15.          Has H.S.E. been notified (in the case of a Major Error)                             Y/N




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     16.          Has CSCI been notified?                                                             Y/N


     17.          Name of Service Manager to whom this form has been sent:                            Date:




     18.          Signature                                                                           Date:




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54 APPENDIX 26

54.1 MEDICINE AND ALCOLHOL: COMBINATION TO BE AVOIDED

No medicine should be administered with alcohol, or given to a resident known to have
consumed a large amount of alcohol. It is important that the GP is made aware of any resident
consuming regular considerable quantities of alcohol, and the possibility of interactions
between any prescribed medicines and alcohol should be confirmed with the pharmacist.
The following list identifies those drugs where a significant interaction with alcohol occurs, and
which may have serious consequences.

  Drug                                                                      Reaction with alcohol

  Disulfiram/Antabuse                                                       Reactions are unpredictable and
                                                                            occasionally severe, and can occur within
                                                                            10 minutes and last several hours, possibly
                                                                            needing oxygen and other supportive
                                                                            therapy. Alcohol contained within other
                                                                            medicines, tonics and toiletries (eg
                                                                            mouthwash) must also be avoided.

  Acamprosate/Campral EC                                                    Flushing face, throbbing headache,
                                                                            palpitations, nausea, vomiting. With large
                                                                            doses of alcohol, irregular heartbeat,
                                                                            hypertension, and collapse. Avoid alcohol
                                                                            contained within other items as above.

  Metronidazole & cefamandole                                               Flushing face, throbbing headache,
                                                                            palpitations, nausea, vomiting.

  Warfarin                                                                  Large amounts of alcohol affect warfarin
                                                                            control by enhancing the anti-coagulant
                                                                            effect.

  Monoamine-oxidase inhibitors                                              Throbbing headache is an early warning
                                                                            symptom of a dangerous rise in blood
                                                                            pressure.

  Anti-depressant drugs                                                     Alcohol enhances the sedating effect of
                                                                            these drugs.

  Anti-hypertensive drugs and other cardio-                                 Enhances the lowering of blood pressure.
  vascular drugs                                                            Flushing, headache and giddiness. Does
                                                                            not usually have severe consequences.

  Opioid analgesics                                                         Alcohol increases sedation and produces
                                                                            blood pressure lowering effects.



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55 APPENDIX 27

55.1      WARFIN: THINGS TO BE AW ARE OF
Warfarin is an anti-coagulant drug commonly used to reduce the clotting power of blood in order to
prevent venous thrombosis (clotting in veins) and pulmonary embolism (clotting in the arteries of
the lungs). Wafarin is also used to prevent blockage of arteries in patients with rheumatic heart
disease and atrial fibrillation (irregular heart beat).

Medicines interacting with warfarin:-

Aspirin, Ibuprofen, Boldo, St John‟s Wort, some chilblain tablets. (Occasionally, interacting
medicines may be co-prescribed, but always check with GP.)
Bleeding might not be due to a warfarin over-dose but any of the above signs should be reported to
the service user‟s GP.

It is important that service users who take warfarin have their prothombin (clotting) time checked
regularly by means of an INR test. This will involve a small blood sample being taken and sent for
analysis. The result of the test will be used to confirm the dose taken or to adjust it if necessary.
Managers should ensure that service users who take warfarin have these tests regularly and that a
system is in place to record and action any dose changes that may be required after a test.

Very many medicines and a number of foods interact with warfarin and may have the effect of
reducing the effect of warfarin or of increasing it. Prescribed medicines will have been checked for
possible interactions (though if you have concerns, do ask your pharmacist) but it is very
important that no other medicines, or vitamins, whether over the counter from a pharmacy or
alternative medicines (herbal etc) from a health food store are taken without first checking with the
pharmacist or doctor. This information should be emphasised particularly to family and friends who
may purchase medicines and vitamin supplements for the service user.

Warfarin also interacts with a number of foods so a consistent diet should be eaten so that the
effect of food does not vary too much. For example, it is known that excessive quantities of some
green vegetables can seriously alter the effect of warfarin, however, it would not be suggested that
green vegetables be avoided, simply that the quantities eaten be average and consistent.

Food and drink interacting moderately with warfarin
Alcohol, avocado, broccoli, brussel sprouts, food supplements and replacements such as Ensure
etc (obtain advice if this or any other supplement is needed), garlic, ginger, green tea, ice cream,
mango, soy protein, spinach, tonic water. CRANBERRY JUICE must be avoided by service users
on warfarin.

Symptoms of warfarin over-dosage or bleeding
Regular monitoring of warfarin effect, (INR tests) should ensure that overdosing does not occur.
However, it would be wise to be aware of the symptoms and signs of bleeding and, if these occur,
to notify the GP immediately, or NHS Direct if out of hours.

Excessive bruising, nose-bleeds, blood in urine, blood in motions (black specks or sticky tarry
motions), cuts bleed excessively, purple blotches on ends of toes, „coffee grounds‟ vomiting,
changes in vision, service user is pale, clammy, light-headed, has an abnormally rapid pulse.


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56 APPENDIX 28

56.1 MONOAMINE OXIDASE INHIBITORS: FOODS TO BE AVOIDED

Monoamine Oxidase Inhibitors (MAOIs) interact with a number of Foods

Monoamine oxidase inhibitors are antidepressant drugs. They are used less frequently these
days, however it is important to identify service users who may be taking them as they react
seriously with a number of foods which contain tyramine.

Foods containing tyramine
cheese
pickled herring
broad beans
Bovril
Oxo
alcohol
salami
caviar
chicken liver
beef liver
soy sauce
avocados
game ( meat that has been hung in order to develop a strong „gamey‟ flavour).

MAOI Drugs


Generic Name                                                          Propriety Name

Phenelzine                                                            Nardil
Isocarboxizide
Tranylcypromine                                                       Parnate
Moclbemide                                                            Manerix
Selegiine                                                             Eldepril




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57 APPENDIX 29

57.1 MEDICINES W HICH INTERACT WITH GRAPEFRUIT



A number of medicines interact with grapefruit juice, particularly the M/R and S/R (that is
monitored release and slow release) forms of the drugs. The interaction increases the
bioavailability of the drugs so that, instead of releasing in the body over 12 hrs or 24 hrs, they
are released within an hour or two.

It was first thought that the problems were only encountered with grapefruit juice, particularly
juice packed in cartons (which is made from the whole fruit). New evidence, however, from
Australia is now changing this opinion as problems have been observed with fresh grapefruit
juice.

The advice now is that patients taking any of the following medicines should not take any form
of grapefruit.
Many drugs react with grapefruit juice but only a few, listed below, are so affected by the
interaction that they should be avoided together.



  Generic Name                                                             Propriety Name
  Lipitor                                                                  Amlodipine
  Istin                                                                    Atorvastatin
  Ciclosporin                                                              Neoral, Sandimum, Sangcya
  Felodipine                                                               Plendil
  Itraconazole                                                             Sporanox
  Lacidipine                                                               Motens
  Lercanidipine                                                            Zanidip
  Lovastatin
  Midazolam                                                                Hypnovel
  Nicardipine                                                              Cardene
  Nifedipine                                                               Adalat, Adipine, Cardilate, Coracten,
                                                                           Coroday, Fortipine, Hypolar Regard,
                                                                           Nifedipress, Slofedipine, Tensipine
  Nimodipine                                                               Nimotop
  Nisoldipine                                                              Syscorme
  Tacrolimus                                                               Prograf
  Terfenidine                                                              Triludan
  Verapamil                                                                Cordilox, Securon, Univer, Verapress,
                                                                           Vertab




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58 APPENDIX 30


58.1 FAX BACK FORMS FOR GP‟S

FAX  CONFIRMATION     OF                                                PRN              (WHEN        REQUIRED)
MEDICATION DIRECTIONS


The purpose of this fax is to fulfil the legal requirement for the directions for the medication for our
resident to be confirmed explicitly. Employees and carers are not trained nurses. They make no
claim to have clinical skills and they are not covered by Derby City Council to undertake such
decisions. Please return within 48 hrs of receipt.




 GP Surgery Practice stamp                                 Date……………………………………..



                                                           Client……………………………………..



                                                           DoB………………………………………



Name and fax no. of establishment



………………………………………………………………………………………….



Name of medication to be administered „as required



………………………………………………………………………………………



For what condition or situation is this to be administered?




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………………………………………………………………………………………



How would this manifest?



……………………………………………………………………………………….



How much should be given?..............................................................................



How long after the first dose can a further dose be given?................................



Maximum dose to be given in 24 hours ?...........................................................



Signature of Prescriber ………………………………………………………………



(can be signed by Non Medical Prescriber after liaison with GP; stating name of GP who authorised)




This form derives from NCC medication policy which was drawn up with input from NCC. The requester will
have tried to resolve the problem with other agencies (pharmacist, nursing staff) before using this form.




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FAX BACK 2



FAX CONFIRMATION OF PRESCRIBER DIRECTIONS


The purpose of this fax is to fulfil the legal requirement for the directions for the medication for our
resident to be confirmed explicitly. The employees and carers are not trained nurses. They make
no claim to have clinical skills and they are not covered by Derby City Council to undertake such
decisions. Please return within 48 hrs of receipt.




 GP Surgery Practice stamp                                 Date……………………………………..



                                                           Client…………………………………



                                                           DoB………………………………………



Name and fax no. of establishment



………………………………………………………………………………………….

This patient is under my care. I authorise directions regarding his/her medication(s)

Name of Medicine and Strength here:



…………………………………………………………………………………………………………………
…………………………………………………………………

That the medicines be administered (use this section to specify a dose quantity and frequency/
time of day.

…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………….




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That the medicines are not available in a suitable soluble, dispersible or otherwise liquid
form □ (tick if applicable)



That the tablets should be crushed/ the capsules should be opened prior to administration
(delete as applicable).



The crushed tablets/ contents of the opened capsules may be administered in soft food
(delete as applicable).



Any other specific directions/ instructions regarding method of administration:

…………………………………………………………………………………………………………………
…………………………………………………………………



Signature of Prescriber………………………………………………………………

(can be signed by Non Medical Prescriber after liaison with GP; stating name of GP who authorised)



This form derives from NCC medication policy which was drawn up with input from NCC .The requester will have tried to resolve the
problem with other agencies (pharmacist, nursing staff) before using this form.




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59 APPENDIX 31


59.1 INDUCTION TOOL KIT

Training and Induction Power point presentation to be forwarded on request. Alternatively,
presentation can be accessed via Policy Library.

          Policy Library




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