City & Guilds Unit 116: Support the use of Medication in Social Care Settings

Unit 116: Support the use of Medication in Social Care

Settings

Candidates’ Work Book

2

Contents

Title Page Number Learner Profile 4

Form 4: Expert / Witness Status List 5

Form 9A: Evidence Location Sheets 6

Form 10: Unit Assessment and Verification Declaration

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Form 11B: Summary of Unit and Qualification Achievement

11

Unit 116.1: Understand the Legislative Framework for the use of Medication in Social Care Settings

Task 1.1 13

Task 1.2 17

Task 1.3 18

Task 1.4 18

Task 1.5 19

Unit 116.2: Know about Common Types of Medication and their use

Task 2.1 21

Task 2.2 23

Unit 116.3: Support the use of Medication in Social Care Settings

Task 3.1 25

Task 3.2 26

Task 3.3 27

Unit 16.4: Understand the Techniques for Administering Medication

Task 4.1 29

Task 4.2 30

Task 4.3 31

Unit 16.5: Be able to Receive, Store and Dispose of Medication Supplies Safely

Task 5.1 33

Task 5.2 34

Task 5.3 34

Task 5.4 35

Unit 116.6: Know how to Promote the Rights of the Individual when Managing Medication

Task 6.1 37

Task 6.2 38

Task 6.3 39

Task 6.4 39

Task 6.5 41

Unit 116.7: Be able to Support the use of Medication

Task 7.1 42

Task 7.2 43

Task 7.3 44

Task 7.4 45

Task 7.5 47

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Unit 116.8: Be able to Record and Report on use if Medication

Task 8.1 49

Task 8.2 49

Task 8.3 49

Notes pages 50

Assessment Plan, Review and Feedback 53

Form 7: Questioning Evidence Record 56

Performance Evidence Record (x3) 58

Cornwall Council Department for Children, Schools and Families Policy and Procedure for the Administration, Control and Recording of Medicines for Establishments (CC126 Revision)

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Medication Competency Assessment (DRAFT) 81

Cornwall Council Medication Form 85

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Learner Profile

If you have a CV you can use that instead of this form.

Name

Place of Work

Outline of current job role

Previous relevant work roles and responsibilities, including voluntary work

Previous relevant qualifications and training

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Form 4 Expert / Witness Status List

Qualification title: _________________________________________________________

Unit title: ________________________________________________________________

Candidate name: __________________________________________________________

Please ensure that all witnesses who have signed the candidate’s evidence or written a report are included on this witness status list. All necessary details must be included and signed by the witness as being correct.

Witness name and signature Status* Professional relationship to candidate**

Unit or outcomes

witnessed

Date

*Witness status categories

1. Occupational expert meeting specific qualification requirement for role of Expert Witness; 2. Occupational expert not familiar with the standards; 3. Non-expert familiar with the standards; 4. Non-expert not familiar with the standards.

**Professional relationship to candidate

Manager = M Supervisor = S Colleague = Coll Customer = Cus Other (please specify) __________

Assessor signature: ______________________________ Date: ___________________________

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Form 9A Evidence Location Sheet

Candidate name: __________________________________________________________

Unit number/title: 116.1 - Understand the legislative framework for the use of medication in social care settings

Item of evidence Loc* Ref Link to assessment criteria (√)

1 2 3 4 5 6 7 8 9 10

Written Evidence12 p 1

Direct Observation p 2

Oral Questions p 3

Witness Testimony p 4

Unit number/title: 116.2 - Know about common types of medication and their use


1 2 3 4 5 6 7 8 9 10

Written Evidence p 1


Oral Questions p 3


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Candidate name: __________________________________________________________

Unit number/title: 116.3 - Understand roles and responsibilities in the use of medication in social care settings


1 2 3 4 5 6 7 8 9 10



Oral Questions p 3


Unit number/title: 116.4 - Understand techniques for administering medication


1 2 3 4 5 6 7 8 9 10



Oral Questions p 3


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Candidate name: __________________________________________________________

Unit number/title: 116.5 - Be able to receive, store and dispose of medication supplies safely


1 2 3 4 5 6 7 8 9 10



Oral Questions p 3


Unit number/title: 116.6 - Know how to promote the rights of the individual when managing medication


1 2 3 4 5 6 7 8 9 10



Oral Questions p 3


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Candidate name: __________________________________________________________

Unit number/title: 116.7 - Be able to support use of medication


1 2 3 4 5 6 7 8 9 10



Oral Questions p 3


Unit number/title: 116.8 - Be able to record and report on use of medication


1 2 3 4 5 6 7 8 9 10



Oral Questions p 3


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Form 10 Unit Assessment and Verification Declaration Qualification title: _______________________________________________________________________

Unit number and title: ____________________________________________________________________

Candidate Declaration

I confirm that the evidence listed for this unit is my own work.

Candidate name: ________________________________________________________________________

Signature: _______________________________________________________ Date: __________________

City & Guilds registration / unique learner number (ULN): _______________________________________

Assessor Declaration

I confirm that this candidate has achieved all the requirements of this unit with the evidence listed. (Where there is more than one assessor, the co-ordinating assessor for the unit should sign this declaration.)

Assessment was conducted under the specified conditions and context, and is valid, authentic, reliable, current and sufficient.

Assessor name: _________________________________________________________________________

Assessor signature: _______________________________________________ Date: __________________

Countersignature: (if relevant) ______________________________________ Date: __________________

(For staff working towards the assessor qualification)

Internal Verifier Declaration

I have internally verified the assessment work on this unit by carrying out the following (please tick):

sampling candidate and assessment evidence Date:

discussion with candidate Date:

observation of assessment practice Date:

other – please state: Date:

I confirm that the candidate’s sampled work meets the standards specified for this unit and may be presented for external verification and/or certification.

Not sampled

Internal verifier name: ____________________________________________________________________

Internal verifier signature: __________________________________________ Date: __________________

Countersignature: (if relevant) ______________________________________ Date: __________________

(For staff working towards the internal verifier qualification)

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Form 11B Summary of Unit and Qualification Achievement

Candidate name: ________________________________________________ Signature: __________________

City & Guilds registration number: __________________________________ Date: _____________________

Centre name: __________________________________________________ Centre number: _____________

Unit Title Internal Verification Grade achieved

(if appropriate)

Signatures

Date Types of evidence

(see key)

Assessor* Candidate IV* EV (if sampled)

Key for types of evidence

(please extend if necessary):

O = Observation; Q = Questioning; P = Work products; C = Candidate/Reflective account; S = Simulation; PD = Professional discussion;

A = Assignments, projects/case studies; WT = Witness testimony; ET = Expert witness testimony;

*If there is a second line assessor/IV, both must sign.

Competence has been demonstrated in all of the units/the qualification recorded above using the required assessment procedures and the specified conditions/contexts. The evidence meets the requirements for validity, authenticity, currency, reliability and sufficiency.

Internal Verifier signature: _______________________________________ Date: _____________________

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Unit 116 /1: Understand the Legislative Framework for the use of

Medication in Social Care Settings

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TASK 1.1

Identify legislation by completing the table below and outline what the law states about the

use of medicines in social care settings.

Legislation Identify Key Points Disability Discrimination Act 1995

SEN & Disability Act 2001

Health & Safety at Work Act 1974

Control of Substances Hazardous to Health Regulations 2002

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Misuse of Drugs Act 1971 & Misuse of Drugs Regulations 2001

The Data Protection Act 1998

Hazardous Waste Regulations 2005

The Human Rights Act 1998

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The Health & Social Care Act 2001

The Education Act 1996

The Children Act 1989

Mental Capacity Act 2005

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NMC Code of Conduct Safe Handling of Medicines

Care Standards Act 2000

Access to Health Records Act 1990

Administration and Control of Medicines in Care Homes and

Children’s services 2003

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TASK 1.2

Legal classification of medicines

There are various legal controls over the sale and supply of medicines as set out in the Medicines Act 1968. The Act classifies the medicines into three categories. Using the table below, outline each category.

Classification Category Description of Term

Prescription Only (POM)

Pharmacy (P)

General Sale List (GSL)

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TASK 1.3

Using the space below outline the main points from your setting’s medicine policies and

procedures and explain your role and responsibility.

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TASK 1.4

Think about your policy and state three ways it reflects and incorporates legislative

requirements.

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TASK 1.5

Explain below why it is important for setting’s to have a policy in place for the administering of

medication and why it is important to reflect and incorporate legislative requirements.

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Unit 116.2: Know about Common Types of Medication and their use

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TASK 2.1

Most people will need to take medication at some point in their lives, no matter how healthy they are. There are huge numbers of different medications available and they are developed to provide the best possible treatment for various health conditions. Medication must always be taken properly and the correct doses as prescribed by doctors and pharmacists should be strictly adhered to. Advice should also be sought before taking medication as not all medications are suitable for everyone.

Using the table below list common medications, conditions for which they may be prescribed and the possible side effects and adverse reactions a person may have to these medications. An example has been given for you.

Type of Medication Conditions Side Effects/Adverse Reactions

Paracetamol Headache, muscle ache, dental pain

Skin rash, damage to kidney and liver and disorders affecting the blood

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TASK 2.2

Reflecting on your own personal practice describe a scenario where you have had to

administer medication to a child or young person outlining the medication and the

condition for which it has been prescribed. Has this child ever had an adverse reaction to

this medication? If so explain how you dealt with this.

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Unit 16.3: Support the use of Medication in Social Care Settings

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TASK 3.1

Prescribed medication will be clearly labelled. List below information that will be found on the label of prescription medication.

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TASK 3.2

Complete the table below describing the roles and responsibilities in the use of medication

in a social care setting.

Person involved in medication Roles and Responsibilities

Prescribing

Dispensing

Supporting use of medication

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TASK 3.3

Describe below your setting’s policies and procedures for administering over the counter

remedies and supplements and your responsibility in relation to use of such medicines.

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Unit 116.4: Understand the Techniques for Administering Medication

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Medication route refers to the way that a medicine is introduced into the body. This is determined by the type of medication being administered, the desired absorption rate and the specific site of action (where the medication needs to have an effect).

TASK 4.1

Describe the medication routes below:

Oral:

Sub Lingual:

Enteral:

Mucosal:

Parenteral:

Inhalation:

Intranasal:

Topical:

Rectal:

Transdermal:

Subcutaneous ingestion:

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TASK 4.2

There are many different forms of medication. Use the format below to list and briefly

describe the commonly used types. An example has been given for you.

Tablets

swallowed orally

Forms of medication

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TASK 4.3

Describe how the following items of equipment are used in the administration of medication

and why they are important.

Calibrated Spoons:

Droppers:

Medicine Cups:

Oral Syringes:

Nasogastric Tube:

Hypodermic Syringes:

Gloves:

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Unit 116.5: Be able to Receive, Store and Dispose of Medication Supplies

Safely

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TASK 5.1

Read the statements below and tick the appropriate box for each statement

Statement about Medication True False You should know the name, dosage and side effects, if any, of all medications you are responsible for administering

You should always follow the instructions on the label carefully

It is ok to transfer drugs from one container to another

Unused medicines can be disposed of with everyday waste

It is ok to change a medication schedule without first checking with a doctor

You should always obtain parental consent to administer medication to a child or young person

Used hypodermic needles should be disposed of in a sharps bin

“Over the counter” medications can be taken for as long as needed without seeking medical advice

Always reorder repeat medication before you run out of it

If an error occurs when administering medication it must be reported immediately and emergency medical advice obtained

You can double a dose of medication if the previous dose was forgotten

Medication should be stored away from children

If two people use the same medication it is ok to use the other persons sometimes

Untrained people can administer medication such as EPI pens

Medicines should be stored at the correct temperature

Some medication will need specialist training to administer to patients

If an individual vomits after being given a dose of medication it is ok to give another dose immediately

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TASK 5.2

Describe how you receive medication in your setting in line with agreed ways of working

and following organisational policies and procedures.

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TASK 5.3

Explain the storage systems in place for medication in your setting and the reasons why

these may differ depending upon the medication.

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TASK 5.4

List 4 possible situations where it may be necessary to dispose of medication.

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Describe how you dispose of unused or unwanted medication safely and explain why this is

important.

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Unit 116.6: Know how to Promote the Rights of the Individual when

Managing Medication

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TASK 6.1

Using the table below explain the importance of these principle in the use of medication.

Principle Importance

Consent

Self-Medication or Active Participation

Dignity and Privacy

Confidentiality

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TASK 6.2

Explain how you can promote an individual’s independence when managing medication and

how risk assessment can be used to promote this.

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TASK 6.3

List below types of medication that you should be aware of that may require the necessity

for privacy and respect for an individual’s dignity and then explain why this is important.

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TASK 6.4

Using a blank risk assessment form from your setting, identify risks and hazards that could

occur when allowing an individual to self-medicate or as an active participant.

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TASK 6.5

Using the format below, list ethical issues that could arise over the use of medication and

then give a brief explanation how these issues can be addressed.

Ethical Issues

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Unit 116.7: Be able to Support the use of Medication

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TASK 7.1

It is essential that any child or young person in your care has up to date information

kept about them detailing their medical history and any medications that need to be

administered by carers in the setting. Describe below how information is kept in your

setting and how you access this information to ensure the correct medication is given

and in the correct manner.

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TASK 7.2

Using reflection on your own practice write an account about how you have

supported an individual to use medication in a way that ensures and promotes safety

and dignity, hygienic practice and where possible active participation.

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TASK 7.3

Before administering medication to a child or young person there are procedures you

need to think about to ensure it is administered correctly. List and briefly describe

these procedures below.

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TASK 7.4

Using the table below describe how you address practical difficulties that may arise

when administering medication.

Practical Difficulties Solution

Lost medication

Missed medication

Spilt medication

An individual’s decision not to take

medication

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Difficulty in taking medication in its prescribed form

Adverse reaction

Wrong medication used

Vomiting after taking medication

Discrepancies in records for directions of use

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TASK 7.5

As you have learnt through previous tasks, there are many different types of medication and

routes it can be administered. Some types of medication may only need to be administered

occasionally if symptoms arise and others on a regular basis.

List below the types of medication that you would need extra training to administer to a

child or young person and describe how you would access further information and support

about the use of such medicines.

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Unit 116.8: Be able to Record and Report on use of Medication

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TASK 8.1

Using a medication form from your setting think of a real or fictitious scenario where you

would administer a medication and complete the information. If using a real situation you

must use a fictitious name to ensure confidentiality.

TASK 8.2

Highlight the statements in the table below that will help ensure you keep accurate and

clear records of medication for individuals.

Writing clearly and neatly Keeping records free from dirt and spillages

Drawing doodles to make the records more fun

Keeping the information up to date

Being detailed and relevant Using as many long words as possible

Writing your own opinion wherever possible Keeping records tidy and organised

Changes in behaviour clearly noted

TASK 8.3

Describe lines of reporting problems associated with medication and who you would report

your concerns and findings to in line with your settings agreed ways of working.

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Notes page:

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Notes page:

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Notes page:

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Assessment Plan, Review and Feedback

Learner name

Assessor name

Unit number(s) and title(s)

This record can be used for planning, reviews, feedback, progress reviews and details of

contact. Remember that all planning should be SMART – Specific, Measurable,

Achievable, Realistic and Time Bound. This should be on-going and completed every time

learner and assessors meet.

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Date action agreed

What has to be done / What has been reviewed and the feedback / Record of judgment or outcome / action targets

Date to be done by / Date done

Learner and assessor signatures

Evidence reference

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Date action agreed

What has to be done / What has been reviewed and the feedback / Record of judgment or outcome / action targets

Date to be done by / Date done

Learner and assessor signatures

Evidence reference

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The above is an accurate record of the discussion.

Learner signature Date

Assessor signature Date

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Form 7 Questioning Evidence Record

Unit: Support Use of Medication in Social Care Settings

Candidate name: _____________________________________________________________________

Unit Learning outcome(s)

Assessment criteria

Questions Answers

116

1

1

Which legislations are most significant to administering

medicine in social care settings?

116

2

1

What are the most common types of medicine’s

administered to children in your care?

116

3

2

Where do your setting’s responsibilities lie with administering over the counter medication?

116

4

3

What equipment may be used to administer medication?

The above is an accurate record of the questioning.

Candidate signature: ______________________________________________ Date: __________________


Internal Verifier signature (if sampled): _______________________________ Date: __________________

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Form 7 Questioning Evidence Record

Unit: Support Use of Medication in Social Care Settings

Candidate name: _____________________________________________________________________

Unit Learning outcome(s)

Assessment criteria

Questions Answers

116

5

2

How do your store medication in your setting to ensure their

safe keeping?

116

6

3

What ethical issues may arise when administering

medication and how may these be addressed?

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7

3

What strategies are in place to ensure medication is

administered correctly?

116

8

1

How do you record the use of medication and any changes

that may occur with the individual?

The above is an accurate record of the questioning.

Candidate signature: ______________________________________________ Date: __________________


Internal Verifier signature (if sampled): _______________________________ Date: __________________

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Performance Evidence Record

Qualification/unit

Learner name

Use this form to record details of activities (tick as appropriate)

Observed by your assessor

Seen by expert witness

Seen by witness

Self / reflective account

NB. Your assessor may wish to ask you some questions relating to this activity. There is a

separate sheet for recording these. The person who observed/witnessed your activity must

sign and date overleaf.

Date of Activity

Unit(s)

Learning outcome (s)

Assessment criteria

Evidence

Evidence ref(s):

Unit number(s):

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Unit(s)


Assessment criteria

Evidence

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Unit(s)


Assessment criteria

Evidence

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Assessment decisions and feedback to learner

I confirm that the evidence listed is my own work and was carried out under the conditions

and context specified in the standards.


Assessor/Expert Witness* signature Date

*delete as appropriate

Internal Verifier signature (if sampled) Date

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Qualification/unit

Learner name




Seen by witness





Date of Activity

Unit(s)


Assessment criteria

Evidence

Evidence ref(s):

Unit number(s):

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Unit(s)


Assessment criteria

Evidence

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Unit(s)


Assessment criteria

Evidence

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Qualification/unit

Learner name




Seen by witness





Date of Activity

Unit(s)


Assessment criteria

Evidence

Evidence ref(s):

Unit number(s):

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Unit(s)


Assessment criteria

Evidence

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Unit(s)


Assessment criteria

Evidence

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CORNWALL COUNCIL CC126 Revision DEPARTMENT FOR CHILDRENS ,SCHOOLS AND FAMILIES Community Care Service Policy and Procedure POLICY AND PROCEDURE FOR THE ADMINISTRATION, CONTROL AND RECORDING OF MEDICINES FOR ESTABLISHMENTS 1. Policy Statement 1.1 People accessing Day Services or Short Break Care provided by Cornwall Council Department

of Adult Social Care should be encouraged to retain, administer and control their own medication in order to maximise their independence and retain control over their own lives. This will require risk assessment, including Mental Capacity assessment, to ensure the safety of the person and of others.

1.2 Some people will be assessed as able to self-medicate, while others, i.e. children and young

people within Children, Schools and Families will need assistance. In these cases staff will need to take complete responsibility for the safe keeping and administration of medicines.

2. Definitions 2.1 Controlled drugs – These are medicines with the potential for abuse for which special legal

precautions are necessary. A current list of these can be obtained from http://drugs.homeoffice.gov.uk or individual queries can be made to the community pharmacist.

2.2 MAR sheets – medication administration record sheets that show the individual

administration to a service user. See SC/270 (Sample No. 204) 2.3 Consent – Where people are deemed by a health professional to lack the mental capacity to

consent, their carer or advocate may do so on the grounds that it is in the person’s best interests.

3. Legal Framework 3.1 Medicines Act 1968 and amendments Misuse of Drugs Act 1971 (Controlled Drugs) and amendments COSHH Regulations 1999 Care Standards Act 2000 (Receipt, storage and administration of medicines) Access to Health Records Act 1990 Data Protection Act 1998 Hazardous Waste Regulations 2005 Administration & Control of Medicines in Care Homes and Children’s Services June 2003 Mental Capacity Act 2005

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4. Pharmacy Advice 4.1 Cornwall & Isles of Scilly PCT has an arrangement with community pharmacists to provide

advice and guidance to service users and staff. This Service Level Agreement is in line with National Minimum Standards and requires participating pharmacists to offer advice and support regarding:

proper and effective ordering of drugs

clinical and cost effective use

safe storage, supply and administration

proper record keeping.

5. Categories of Medications 5.1 The law distinguishes between different categories of medicine. The categories are:

Prescription only medicine – obtained on a prescription from the doctor, dentist or nurse prescriber.

Controlled drugs – specific medicines such as Morphine, Diamorphine (heroin), Cocaine, Pethidine, etc. Because of the potential for misuse, special additional restrictions apply to the prescription, storage, administration and recording of these drugs.

Pharmacy medicine may only be purchased from a community pharmacy (chemist’s shop) with the pharmacist present.

General sales list medicine (examples include paracetamol, proprietary cold remedies like “Lemsip”, etc.) can be purchased through a wide variety of retail outlets such as supermarkets and garages.

6. Responsibility for Drug Administration 6.1 It is the overall responsibility of the Establishment Manager to ensure that a safe

environment exists in relation to the storage, administration and disposal of medicines belonging to service users that have been handed in for safekeeping or for staff to administer. The Manager must promote a safety conscious approach in which all staff involved understand what is expected of them.

6.2 All new staff should read and understand the policy and procedure for the administration,

control and recording of medicines and sign to confirm understanding of this policy. 6.3 All staff should have access to the British National Formulary and any other appropriate

literature to assist with identifying medication and administration of such. 6.4 The Establishment Manager is responsible for ensuring only staff who have been trained

administer medication. (See Section 19) 6.5 The Manager, or a named officer to whom the manager has delegated responsibility, is

responsible at any given time for:

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the security of medication including the possession of keys

the receipt of medicines

the administration of medicines to particular service users

the recording of the administration of medicines

the recording of the disposal of medicines. 6.6 A risk assessment for each service user should determine the support they need with

medication with this being reviewed on an annual basis or earlier when there is a change of circumstances.

7. Supply of Medicines 7.1 Medicines are those prescribed by a health professional. Only medicine prescribed for the

individual user may be administered to that person. Prescribed medicines belong to the named individual and must not be given to anyone else.

7.2 The total amount of medicine prescribed is specified on each container, which makes it

easier to check if the medicine has been taken correctly. The pharmacist may add instructions to the label such as “complete the course” or “avoid alcohol”. Should any detail on the label not be clear staff must contact the pharmacist or health professional until they are satisfied that sufficient instructions have been given.

8. Security of medicines 8.1 Medication should arrive in original containers correctly labelled with the doctor’s

prescription and initially accompanied by a signed and dated service user/parent/carer consent form. If this procedure is not adhered to the manager should refer to a Senior Manager.

8.2 Medicine cabinets must be locked at all times except when in use. (This cabinet must be

locked if the nominated officer leaves the area to administer medication). 8.3 Access is restricted to the nominated officer only. 8.4 Keys to the medication cabinets need to be held personally by the nominated officer; either

on the person or in a safe and appropriate place overseen by the nominated officer. 8.5 Controlled drugs should be stored in a cabinet with an inner locked section in accordance

with the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 as amended. 8.6 When off the premises, medication should be stored in a secure container and carried by the

nominated officer. 9. Storage of medication 9.1 A record of all medication received by the service must be kept.

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9.2 All medicines must be stored in the packages/containers as dispensed by the doctor or pharmacist.

9.3 Every establishment must have a locked medicine cabinet available for the storage of

medication and any over the counter preparations that have been brought to the establishment by service users.

9.4 Only medicines to be stored in the medication cabinet. 9.5 If a medicine requires refrigeration, it must be kept in a separate drug refrigerator, or in

exceptional circumstances in a secure lockable container in a general refrigerator. 9.6 All medicines belonging to service users should be stored in individually labelled areas within the medication cabinet. 9.7 Medicines for internal use should be stored separately from medicines for external use in a

separate locked cabinet or physically separated on different shelves. Disinfectants and other potentially harmful chemicals should be stored in a separate locked cupboard.

10. Disposal of medication 10.1 The Manager/Duty Officer or nominated officer will check all medication cabinets monthly

and record this procedure to ensure:

only medication is being stored in the cabinet

all medication is clearly labelled and in date

there is the minimum amount of service users’ medication stored in cabinets. 10.2 Any medication which is out of date or no longer required needs to be returned to the

pharmacist or sent back to parents/carers for disposal. 10.3 When returning controlled drugs ensure the pharmacist signs the controlled drugs book. 10.4 On the unexpected death of a service user it is important that any personal medication and

record sheets are kept until otherwise advised. 11. Records 11.1 Each service user must have an up to date Agreement for the Administration of Medication

Form SC/269 (Sample No. 203) on file. It will be the responsibility of the Manager or nominated officer to ensure these are regularly checked at least annually and kept up to date.

11.2 The Manager or nominated officer must ensure that a written record using the MAR Sheet

SC/270 (Sample No. 204) is kept of all medication entering the establishment that is being

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administered to service users, leaving the establishment at the end of a session or sent for disposal. The records must contain:

date of receipt of medication entering the establishment

name and strength of the medication

quantity received

service for whom the medication is prescribed

signature of the members of staff receiving the medication. 11.3 For those service users who have epilepsy, the Manager or nominated officer will be

responsible for ensuring there is a current and up to date epilepsy profile and care plan on file.

11.4 When preparing a medication record for a service user, the Manager or nominated officer

needs to ensure that they record each medication a person takes. The name, form, route, strength, dosage and times of each medication need to be recorded clearly.

11.5 The Manager or nominated officer must ensure that any particular instructions e.g. allergies,

soluble, with/before/after food, etc, is recorded on the MAR Sheet SC/270 (Sample No. 204). 11.6 The nominated officer who has prepared the record must sign to verify the procedure. A

second officer then needs to sign the record sheet, confirming that the details are correct. These details must be checked against the current Form of Agreement for Administration of Medication SC/269 (Sample No. 203) and the previous MAR Sheet SC/270 (Sample No. 204). If there are any doubts or confusion about medication or dosage instructions, then the medication must not be given until this has been confirmed with either one or a combination of those people listed below:

parents/ carers

doctor/ GP

community pharmacist

duty doctor. This must then be clarified with the Manager. 11.7 The appropriate recording box must be initialled after medication is given. Staff need to

ensure that the correct box has been initialled i.e. time and date. 11.8 Quantities of regularly prescribed medication should be entered in the shaded

IN box under the correct date. Likewise, medication being signed out needs to be entered in the OUT box. Liquid medication needs to be estimated by volumes (not measured) e.g. ½ or ¼ bottle. When signing medication OUT, two staff must witness that the totals of medication being signed OUT must equal the amounts of medication signed IN and ADMINISTERED during the stay.

11.9 For reasons of hygiene, medication should not be directly handled. Medication should be

counted by using a spatula or counting triangle. 11.10 Any medication coming directly from a pharmacy also needs to be counted in and recorded.

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11.11 Any medication returned to the pharmacy or parent/carer for disposal needs to be recorded on the back of the medication sheet and signed for by the nominated officer and the witness.

11.12 ‘As required’ medications need to be signed in and out using the back of the MAR Sheet

SC/270 (Sample No. 204). 11.13 Any liaison with parents/carers or doctors etc regarding medication needs to be recorded on

the back of the MAR Sheet SC/270 (Sample No. 204) and in the individual service user’s Contact Sheet Form SC/10 (Sample No. 21).

11.14 If there are occasions when an urgent amendment needs to be made to the MAR Sheet

SC/270 (Sample No. 204) this must be made in ink with the person making this amendment signing and dating this entry.

11.15 Completed sheets must be kept in the service user’s personal file. 11.16 If there are service users who have been prescribed controlled drugs then a separate

controlled drugs register with numbered pages must be maintained. In addition to the above guidance for the receipt of medication, this bound book needs to include the balance remaining for each product following each administration, with a separate record page for each service user taking a controlled drug. There should be no crossing outs or obliterations of any kind in this record.

12. Administration 12.1 Staff administering medication will be expected to work towards achieving a relevant

certification. (See Section 18 Training) 12.2 Each service user’s medication has been prescribed specially for them and must not be

administered to anyone else, even if another service user is on the same medication and dosage.

12.3 When administering medication, staff need to check that this is in accordance with the

instructions on the medication containers and on the MAR Sheet SC/270 (Sample No. 204). If there are any discrepancies, refer to the Form of Agreement for Administration of Medication SC/269 (Sample No. 203) or to parents/carers or the GP/pharmacist as necessary (see 11.6).

12.4 Medication needs to be administered directly from the original labelled container. The

removal of medicines from their original containers into other containers by anyone is not acceptable as such secondary dispensing increases the risk to both staff and service user.

12.5 The nominated officer is responsible for ensuring they are aware of all service users’ times

for administration of medication and of any special instructions e.g. to be taken with food. 12.6 It is not acceptable to covertly administer e.g. in food or drink, unless specifically instructed

by the prescriber. 12.7 Both the nominated officer administering the medication and the witness need to check:

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the service user is correct

the medication is correct

the amount is correct

the time and date is correct

the expiry date. 12.8 The staff member should explain to the service user what they are about to do and

wherever possible obtain their consent. This will involve a capacity judgment. If the service user’s capacity fluctuates this judgment must be made on each occasion. If capacity is static then this must be documented and therefore a judgment would not need to be made each time.

12.9 Both staff (nominated officer and witness) must visually witness that the service user has

taken the medication. 12.10 If a service user refuses a medicine, staff cannot force treatment. Advice should be taken

from the carer, GP or community nurse. 12.11 If medication is not administered for any reason an X needs to be recorded in the

appropriate box and the reason recorded and signed on the back of the MAR Sheet SC/270 (Sample No. 204) and also the service users’ Contact Sheet SC/10 (Sample No. 21).

For gross errors e.g. wrong tablet, wrong dose, wrong service user etc advice must be sought immediately from the GP or pharmacist etc. Also the Manager/Duty Officer should inform their Line Manager.

If the medication has not been signed for, this needs to be followed up immediately. If it is

then confirmed that the medication was given, a note of this needs to be written on the back of the person’s medication sheet. Medication MUST NOT be signed for in retrospect.

If it is not possible to contact the member of staff for confirmation, this will also need to be

recorded on the medication sheet and a count made of the person’s medication to establish if there is a high probability that the medication was given or not. If in doubt seek further advice.

12.12 The witness to the administration of medication must sign for these on the MAR Sheet

SC/270 (Sample No. 204), alongside the nominated officer’s signature. Staff must only sign their name to the specific service users they have actually witnessed.

If there is an RGN on the premises who administers medication a witness is not needed.

However it is good practice to have a second person as a witness. 12.13 The Duty Officer/Manager will check and ensure all relevant medications have been

administered and any discrepancies/queries will be followed up immediately by the Duty Officer with the individual staff member.

13. “As required” medication including the administration of emergency medication 13.1 Any medication that is taken “as required” needs to be entered in its separate section on the

MAR Sheet SC/270 (Sample No. 204).

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13.2 Each time these medications are administered, the time, date and person administering

them needs to be recorded in the appropriate box and witnessed. 13.3 In the event of an emergency whereby any invasive treatments are necessary, such as

suppositories, including rectal Diazepam can only be administered by suitably trained staff. Confirm with the Form of Agreement for Administration of Medication SC/269 (Sample No. 203) and refer to care plan or parents/carers for details on administration. Sensitivity is required when administering this procedure. Ensure privacy and dignity for the service user when carrying out this procedure.

13.4 If there is no suitably trained member of staff available to administer emergency medication

the emergency services must be called. 14. Homely Remedies 14.1 These are intended for the occasional treatment of headache, stomach ache, etc. They are

not for regular use. If a service user requires repeated doses of home remedies the GP should be informed. Agreement for the administration of any home remedies should be clarified with the GP in question and recorded on the service user’s file.

14.2 A home remedies list should be compiled by each establishment and kept for reference, and

signed by a pharmacist or GP. 14.3 Purchased medicines, such as cough or cold remedies, contain several drugs which could

interfere with prescribed medicines. Advice should be sought from the pharmacist before purchasing home remedies.

14.4 Details should be entered on the Form of Agreement for Administration of Medication

SC/269 (Sample No. 203) for reference by appropriate parent/ carer. 14.5 The administration of any home remedies should be recorded by the nominated officer and

witnessed on the service user’s MAR Sheet SC/270 (Sample No. 204). 15. Self administrating 15.1 An assessment of mental capacity should be carried out by an appropriate assessor before

self medicating is carried out. This must be supported by robust risk assessments. These assessments should be reviewed via the Care Planning process in order that this procedure is still appropriate. The decision represents a balance between informed choice and risk to the individual or other service users. The Form of Agreement for Self Administration of Medication SC/271 (Sample No. 205*) should be signed by the service user, parents/carers, doctor and Manager/Duty Officer and kept in the service user’s file. The Criteria Checklist for Service User Assessment to Self Administer Medication should also be filled in at this time - Form SC/596 (Sample 206).

15.2 Staff should monitor that the service user keeps their medicines secure at all times and they

do not pose a risk to others. A lockable storage locker/drawer/ container should be made available for each self medicating service user to use, should they so wish, to which the service user and Manager/Duty Officer have a key.

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15.3 If there is concern about the service user’s ability to administer their own medicines safely,

the Manager and health professional together with the service user and their carer and families, agree how much responsibility the service users is able to undertake.

15.4 Discreet checks should be made by staff to ensure that the medicine is being taken correctly

and stored safely. 15.5 Should a service user be assessed as no longer able to safely administer their own medication for whatever reason, staff should explain why the decision has been reached. 16. Service users who are temporarily absent including day trips and outside activities 16.1 If the service user self medicates then staff should confirm that the service user has

sufficient for the duration of the event. 16.2 If the service user’s medication is administered by staff, the Manager/Duty Officer must

arrange for medicines to be taken in their containers and given to a delegated member of staff for administration and safekeeping.

16.3 If the service user’s medication is usually administered by staff but the service user is not

being accompanied by establishment staff, the Manager/Duty Officer must satisfy themselves that the accompanying person has the authority and is competent in the administration of these medicines. If satisfied, the Manager/Duty Officer will arrange for those medicines to be taken in their containers and given to that person for administration and safekeeping. If the Manager/Duty Officer is not satisfied that this person does not fulfil both of these criteria the medication must remain in the establishment. In such a case the Manager/Duty Officer must clearly inform both the service user and the person accompanying them the time of the next administration of medicines and ensure this has been understood.

16.4 It is good practice and required by this policy that administration of medication be recorded

by two members of staff on the MAR Sheet SC/270 (Sample No. 204). However there are occasions, such as member of staff accompanying a small group or an individual service user on a trip into the town, where this is impractical. In such cases it is permissible for one member of staff to undertake both the administration and the recording of this provided a written risk assessment has been carried out and any necessary controls put in place. The administration of the medicine will be recorded on the MAR Sheet SC/270 (Sample No. 204) with an explanation on the back of the sheet and on the relevant contact sheet.

IMPORTANT – This variation cannot be used for the administration of controlled drugs

where two separate members of staff must be involved in the administration and witnessing of such medications.

17 Equality and Diversity - Promoting Choice 17.1 Staff may with the consent of the service user administer prescribed medication, so long as

this is in accordance with the prescriber’s directions. However consent does not mean that a

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service user may at any time refuse to take the medication that the member of staff offers. (See Section 12)

17.2 Service users will also have certain preferences and these may relate to equality and

diversity. The following are of particular concern:

the medication is provided in a gelatine capsule and the resident is vegetarian

service users prefer to have medication given to them by a member of the same sex

the service user observes religious festivals by fasting and prefers not to have medicines given at certain times.

17.3 These specific examples of service user choice and preference should be recognised and

accommodated through the care planning process. 18. Training

18.1

All medicines can only be administered by designated and appropriately trained staff. See

also Professional Advice: Training care worker to safely administer medicines in care homes.

www.cqc.org.uk or Ofsted the current inspection body for Childrens Homes at

[email protected]

18.1 There are three levels of training for care staff.

All staff should receive level 1 (induction). Level 2 (basic) is essential before any member of staff can administer medication.

Level 3 (specialised techniques) relates to those circumstances following an assessment by a healthcare professional including:

rectal administration, e.g. suppositories, diazepam (for epileptic seizure)

insulin by injection

administration through a Percutaneous Endoscopic Gastrostomy (PEG)

giving oxygen. 18.3 Members of staff can refuse to administer medication if they consider they have not

received suitable training and do not feel competent to do so. 19. Principles for the administration of medicine 19.1 In exercising professional accountability in the best interests of service users, staff must:

know the therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contra indications

http://www.cqc.org.uk/

mailto:[email protected]

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be certain of the identity of the service user to whom the medicine is to be administered

be aware of the service user’s care plan

check that the prescription, or the label on a medicine dispensed by a pharmacist, is clearly written and unambiguous

have considered the dosage, method of administration, route and timing of the administration in the context of the condition of the service user and co-existing therapies

check the expiry date of the medication to be administered

check that the service user is not allergic to the medication before administering it

contact the prescriber or another authorised prescriber without delay where contra-indications to the prescribed medication are discovered, where the service user develops a reaction to the medication, or where assessment of the service user indicates that the medication is no longer suitable

make a clear, accurate and immediate record of all medication administered, intentionally with-held or refused by the service users, ensuring written entries and the signature are clear and legible, using its generic or brand name where appropriate and its stated form, together with the strength, dosage, timing, and frequency of administration, start and finish dates and route of administration. It is also the staff member’s responsibility to ensure that a record is made when delegating the task of administering medication in the case of controlled drugs, specify the dosage and the number of dosage units or total course.

Nigel Stephens March 2008 Amended re CSF July 2009 Reviewed January 2011

Area / subject assessed Assessor’s comments (discuss areas of strength and areas for improvement further learning)

Assessed by Observation Questioning Documentation Reflection Discussion

Pass Refer – list actions taken and review date

Organisation Approach to whole procedure General preparation / environment Preparation of equipment Appropriate environment Personal preparation Maintaining privacy and dignity

Relationship and communication With the child – understands the child’s communication methods Age appropriate preparation for the child Support during administration With the assessor With other staff Information for the child and parents Know where to go for help and support

Procedure Performs appropriate hand washing, correctly and at the appropriate times Read and understand administration procedures / guidelines medicines management policy (including controlled drugs)

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Knowledge of the 6 Rs Checking prescription, drug labels and instructions Expiry dates Preparation and administration of the drug(s) Special observations (e.g. for effect of the medicines or tests needed pre-administration) Observation of the child taking medicines Preparation and administration of medicines by other routes:

Midazoam / Oral buccal

Enemas / suppositories

Eye drops

Ear drops

Nasal sprays / inhalers

Nebuliser

Topical creams Medicines given by the enteral route (where applicable) Consideration for child’s comfort Discuss any difficulties encountered (e.g. refusal, partial administration, appropriate administration in difficult circumstances)

Recognition of the sick child and medicines, actions to take

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Recognition of pain or distress Record of drugs given Signing and checking

Application of knowledge How to access information on medicines Uses and purpose of medicines Usual doses Routes of administration Adverse effects Side-effects Contra-indications Understanding of ‘as required’ / prn medicines and knowledge of guidelines / policy

Allergies Identification and recording

Relevant to

medicines

administered in

the House / for

the child.

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Controlled drugs [CDs] Knowledge of the law, CD Guidelines key issues related to CDs and relevant medicines. The role of the Accountable Officer.

Reporting and recording Condition of the child When to ask for advice and where to go for this Dealing with discrepancies Reporting incidents and near misses, knowledge of the process and roles and responsibilities Disposal of medicines

Cleaning and tidying up

Health and Safety in relation to medicines / COSHH

Calculation assessment To include assessment of the ability to calculate mgs to mls and knowledge of the critical nature of these calculations

City & Guilds Unit 116: Support the use of Medication in Social Care Settings

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Transcript of City & Guilds Unit 116: Support the use of Medication in Social Care Settings