Medicines Administration Support (Draft)

NB. The job titles of Community Support Services Manager and Community Support Worker are used in this paper to reflect the roles of the frontline Domiciliary Care Manager and the Domiciliary Care Assistant (public and private sector)

On completion of an assessment, using the concordance tool to assess the level of need, the appropriate category of service procedures should be followed as listed below.

Categories of Community Support Service

Category 1 On medication, requires help ordering and collecting prescriptions and advise on safe storage

Tasks to be included

1. Ensuring safe and secure storage of medicines in the service user's home
2. Prompting or helping service user to order prescriptions
3. Prompting or helping service user to collect prescriptions
4. Note and record any change in service users ability to manage their medication

Category 2 On medication, requires help to open containers and / or reminding to take medication, ordering and collecting prescriptions and advice on safe storage.

Tasks to be included

1. Ensuring safe and secure storage of medicines in service user's home
2. Reminding or helping the service user to order prescriptions
3. Reminding or helping the service user to collect prescriptions
4. Note any changes in the service user's ability to manage their medication
5. Assisting the service user with their prescribed medication, either physically or cognitively

Category 3 On medication, requires supervision with self-medication or total medication management which may include some direct administration.

Tasks to be included in Category 3

1. Ensuring safe and secure storage of medicines in the service user's home
2. Ordering the service user's prescriptions
3. Organising the collection or delivery of the service user's medicines
4. Note any changes in the service user's compliance with the medication regime
5. Supervise self administration or in some cases direct administration of medicines may be necessary.
6. Record administration of prescribed medicines on the Home Based Record Chart or MAR chart.

Category 4 Total medication management which may include some direct administration and invasive procedures.

• Task list to be confirmed following pilot

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Category 1

service user on medication and requires help ordering and collecting prescriptions and advice on safe storage.

Procedure to be followed by the Assessor:

• Following assessment the assessor will include ‘Identified category of medicines administration support' as part of the care package, record this in the care plan and obtain service user / representative recorded agreement using the appropriate consent form.
• The assessor will record the conditions and level of security required for the storage of medication in the care plan after carrying out a risk assessment and consulting with a pharmacist   
• The service user must select one pharmacy to dispense their prescriptions so that a complete patient medication record is available on the pharmacy computer to:

1. Monitor the frequency of repeat prescriptions
2. Monitor dosage changes to prescribed medicines
3. Highlight interactions between newly prescribed and existing medicines
4. Enable the pharmacist to answer medication queries promptly and offer appropriate advice
5. Monitor the return of discontinued / unwanted medicines before disposal

• The assessor will contact the Community Support Service Manager (CSSM) or Independent sector equivalent to agree the care package.
• The assessor will ensure a record of all medication being taken by the service user is passed to the Community Support Service Manager.

Procedure to be followed by the Community Support Service Manager (CSSM):

• Ensure copies of the care plan, medication record and signed consent form are received and included in the Home Based Record in the service user's home.
• Allocate the care package to an appropriately trained and competent Community Support worker making sure that they have all the relevant information regarding ordering, collecting and storage of the service user's medicines.

Procedures to be followed by the Community Support Worker (CSW):

• Ensure that the medication is able to be safely stored in line with the storage instructions. If not, the CSSM must be notified ASAP.
• Ensure the service user knows when medication will next need ordering
• Ensure the service user knows how and when their medicines will be collected or delivered from the pharmacy
• Be alert to any changes in the ability of the service user to manage their medication and report to the CSSM

Category 2

service user on medication and requires help to open containers and / or reminding to take medication and ordering and collecting prescriptions and advice on safe storage.

Procedures to be followed by the Assessor:

• The assessor will explore the problems encountered by the service user in accessing their medication and after consultation with the pharmacist and / or GP propose actions to address the problems e.g. more appropriate containers, aids to help open containers, more simplified medication regime, e.g. MDS
• Following assessment the assessor will include ‘Identified category of medicines administration support' as part of the care package, record this in the care plan and record the service user / representative agreement using the appropriate consent form.
• The assessor will record the conditions and level of security required for the storage of medication in the care plan after carrying out a risk assessment and consulting with a pharmacist.
• The service user must select one pharmacy to dispense their prescriptions so that a complete patient medication record is available on the pharmacy computer to:

1. Monitor the frequency of repeat prescriptions
2. Monitor dosage changes to prescribed medicines
3. Highlight interactions between newly prescribed and existing medicines
4. Enable the pharmacist to answer medication queries promptly and offer appropriate advice
5. Monitor the return of discontinued / unwanted medicines before disposal

• The assessor will contact the Community Support Service Manager (CSSM) to agree the care package.
• The assessor will ensure a record of all medication being taken by the service user is passed to the CSSM.
• The service user's GP should be notified of the outcome of the assessment, including any action or ongoing service requirements, so that this can be noted in the service user's medical records. Where appropriate this can be done via the Single Assessment Process.
• Where required the assessor will also arrange with GP and selected pharmacist to dispense medication in a monitored dosage system (MDS). The type of MDS system used should be decided after consultation with the pharmacist. The MDS should be clearly labelled by the pharmacist.

Procedures to be followed by the Community Support Service Manager:

• Ensure copies of the care plan, medication record and signed consent form are received and included in the Home Based Record in the service user's home.
• Allocate the care package to an appropriately trained and competent Community Support worker ensuring they have all relevant information regarding ordering, collecting and storage of the service user's medicines
• Ensure the worker has copy of detailed care plan including medication times.
• Contact the Pharmacist for advice in the event of service users forgetting to take their medication or contact the Assessor if a service user consistently forgets their medication.
• Contact the GP surgery if any service user refuses to take their medication and then advise the CSW accordingly.

Procedures to be followed by the Community Support Worker:

• Ensure the medication is stored in line with the storage instructions. If not, the CSSM must be notified ASAP.
• Ensure the service user knows when their medication will next need ordering.
• Be alert to any changes in the ability of the service user to manage their medication and report to the CSSM.
• Ask the service user if they have taken their medication and note they have done so in the Home Based Record
• If necessary, open the container for the service user and note when s/he has taken it on the Home Based Record
• If the service user has forgotten to take their medication, record the incident on the home based record and notify the CSSM
• If the service user refuses to take their medication it must be recorded in the Home Based Record and the GP surgery and CSSM informed ASAP.
• Individual doses must not be put out for the service user to self-administer later in the day.
• Ensure that the frequency of 'when required' medication dosing is specified on the care plan, and that all doses taken are recorded on the Home Based Record Chart

Category 3

service user on medication, requires supervision with self-medication or total medication management to include some direct administration.

Procedures to be followed by the Assessor:

• The assessor will explore the problems encountered by the service user in accessing their medication and after consultation with the pharmacist and / or GP propose actions to address the problems e.g. more appropriate containers, aids to help open containers, more simplified medication regime, use of MAR charts, MDS
• Following assessment the assessor will include 'medicines administration support' as part of the care package, record this in the care plan and record the service user / representative agreement using the appropriate consent form.
• The assessor will record the conditions and level of security required for the storage of medication in the care plan after carrying out a risk assessment and consulting with a pharmacist.
• Copies of the consent form must be sent to the GP surgery for inclusion in service user's notes, to Social Services locality office for service user file, and to the Community Support Service Provider.
• The service user must select one pharmacy to dispense their prescriptions so that a complete patient medication record is available on the pharmacy computer to:

1. Monitor the frequency of repeat prescriptions
2. Monitor dosage changes to prescribed medicines
3. Highlight interactions between newly prescribed and existing medicines
4. Enable the pharmacist to answer medication queries promptly and offer appropriate advice
5. Monitor the return of discontinued/unwanted medicines before disposal

• The assessor will contact the Community Support Service Manager (CSSM) or Independent Sector equivalent to agree the care package.
• The assessor will ensure that a record of all medication being taken by the service user is passed to the CSSM.
• The GP should be notified of the outcome of the assessment including any action or ongoing service requirements so that the service users medical records can be updated. Where appropriate this can be done via the Single Assessment Process.
• The assessor will arrange with the selected pharmacist for a Medication Administration Record chart to be provided (MAR chart).
• All medication must be clearly marked by the pharmacist with the name of the drug, the dosage, time(s) of day required, and any warnings or special arrangements.
• The MAR chart will cover a 4 week period and will be synchronised with the service user's 28 day prescription
• Where required the assessor will also arrange with GP and selected pharmacist to dispense medication into a monitored dosage system (MDS). The type of MDS system used will be decided after consultation with the pharmacist. The MDS must be clearly labelled by the pharmacist.  

Procedures to be followed by the Community Support Service Manager:

• Ensure copies of the care plan, medication record and signed consent form are received and included in the Home Based Record in the service user's home.
• Allocate the care package to an appropriately trained and competent Community Support worker (CSW) ensuring they have all relevant information regarding the ordering, collecting and storage of the service user's medication.
• Ensure the MAR chart is in place in the service user's home, check that, where appropriate, an MDS or other medicines support aids are in place and that the medication has been clearly labelled.
• Ensure the worker has copy of detailed care plan including medication times and is clear about the service she or he is to provide.
• Contact the pharmacist for advice in the event of service users forgetting to take their medication or contact the GP surgery if a service user consistently forgets their medication.
• Contact the GP surgery if any service user refuses to take their medication and then advise the CSW accordingly.
• Contact the Pharmacist when alerted by the CSW that 'as directed' labelled medication has been found at the service users home. Advise the CSW to return the medication to the dispensing Pharmacist who will contact the prescriber for clarification, and re-label it.
• The manager should note that the worker should not assist with administering medication that has not been prescribed by the GP or that is not on the MAR chart.   

Procedures to be followed by the Community Support Worker:

Note. These procedures should be read in conjunction with the guidelines leaflet for community support workers.

• Ensure the medication is stored in line with the storage instructions. If not, the CSSM must be notified ASAP.
• Ensure the service user knows when medication will next need ordering.
• Be alert to any changes in the ability of the service user to manage their medication and report to the CSSM.
• Prompt or supervise the self-administration of medicines and record the service user compliance in the Home Based Record or the MAR chart when supplied
• Where necessary, open the container for the service user and note when she or he has taken it on the Home Based Record or the MAR chart when supplied
• An individual has the right to refuse medication. If the service user refuses to take their medication it should be explained that the medication has been prescribed to maintain their health. If the User still refuses to take the medication this must be recorded on the MAR chart and the GP surgery and CSSM informed immediately. Outside of normal working hours the CSSM should be informed immediately and the GP surgery at the earliest time
• Individual doses must never be put out for a service user to self-administer later in the day.
• The worker should not assist with administering medication that has not been prescribed by the GP or that is not on the MAR chart.
• The Worker must not assist service users defined as category 2 and 3 dependency with medication marked ‘as directed'. Where medication is found marked in this way the Worker must inform the CSSM, who will inform the pharmacist, and advise the Worker of the appropriate action to take e.g. returning the medication to the dispensing pharmacy.

Medications which can be administered in Category 3.

The medicine concordance risk assessment will have identified service users where help is needed. A Health Professional whether a community, psychiatric, or learning disability nurse should be accountable for managing any risk for a specific patient situation relating to a specific patient and delegating tasks appropriately

1. Administration of oral medication including tablets, capsules, liquids, lozenges and powders
2. Administration of 'when required' oral medications
3. Application of creams, lotions, scalp applications, shampoos and skin patches. (non-invasive application only) N.B. Where skin patches are morphine based drug controlled specific training for administration to the individual will be required.
4. Instillation of eye drops using compliance aids
5. Instillation of nose drops or ear drops.
   NB. If the service user is on multiple drops for eyes, nose or ears then delegation of this task is not suitable.
6. Application of eye ointments
7. Inhalers where the use of compliance aids can make self-administration successful. Where compliance aids are not appropriate then the Home Care worker may provide additional assistance if it is underpinned with a written Medication risk assessment and any appropriate training and information that is required to ensure the safety of both the service user and the Home Care Worker. NB If service user is on multiple inhalers then delegation of this task is not suitable.
8. Insulin Pens. Loading an insulin pen prior to use can facilitate self-administration in service users with manual dexterity problems. This should only be permitted if it is underpinned with a written Medication risk assessment and Nursing Services should provide training on an individual basis. Only Community support workers who have completed the required training would be permitted to carry out the task.
9. Non-Medicine Forms. This includes surgical stockings, emptying catheter bags, changing of night catheter bag, and assisting with supplementary feeds. Assisting in these situations should only be permitted following a joint Health and Social Services needs assessment, which should be recorded in the Care Plan. Training for the use of these items should be provided on an individual basis by Nursing services or Pharmacy whichever is the most appropriate source.
10. Oxygen - assistance is restricted to changing the valves on cylinders and enabling the service user to reach the oxygen.
11. Wound care - first aid only.

Tasks not listed above but will be additionally tested in the pilot to determine the correct category:

• Changing daytime catheter bags
• Long term stoma care
• Glucose monitoring (finger prick)
• Non-complex dressings

Tasks that can be carried out by Domiciliary Care Staff under Category 3 on an exceptional basis i.e. when trained for a particular service user only.

1 PEG feeding.

NB. At this current time the list of tasks set out below will not be undertaken by Community Support Workers (Domiciliary Care Assistants). However the service, once established, will be subject to review and continuous improvement which will include review of category 3 tasks and may well involve changes in the future.

Tasks not to be undertaken by Domiciliary Care Assistants

Medications:

• Administration of Adrenaline and related products by 'Epipen'
• Administration by Insulin Pens.
• Application of vaginal or rectal creams.
• Administration of suppositories or enemas.
• Administration by intra muscular injection
• Intravenous injections
• Subcutaneous injections.
• Insertion of pessaries.

Non-medicines care:

Care of bowel and bladder.

• Manual evacuation of the bowel.
• Initiation of stoma care or continence aids.
• Unblocking of urinary catheters.
• Removal of any catheters or tubes from the bladder.

Feeding:

• Naso-gastric tube feeds.
• Intravenous infusions.

Care of skin:

• Complex dressings
• Deep wound or pressure sores.
• Dressing of new limb stump, or other post operative wounds.

Other:

• Glucose monitoring.

Category 4

This category of service will be carried out by the Intermediate Care Support worker role which is currently being developed.

It will include more complex tasks, some of which may be invasive, and could include some of those listed above.

• Task list to be confirmed following pilot.