Home care medication procedure
Summary
This document outlines the roles, responsibilities and procedures for assisting
people living in their own homes with prescribed medication. It sets out the
procedure for handling and administering medicines, and for their safe
storage and disposal. It outlines what documents should be used and how
records should be kept. Levels of medication support
Interim Procedure
GP's across Hertfordshire will no longer be completing the HC420
medication record forms.
The CCG’s have commissioned a 6 month pilot from July 2014 to trial a
pharmacy model where the pharmacist is responsible for the production,
maintenance and evaluation of the MAR (Medicines Administration
Record). This will be piloted for 6 months from July 2014 in the
Stevenage; Bushey and Watford areas. HCS will evaluate the service
and look to expand this across Hertfordshire. You will be kept informed
re; progress.
As an interim measure, the following procedure has been agreed and
issued with regards to the completion of the HC420’s. Please note that
this may mean, in some areas, this differs from current procedures. The
whole document will be reviewed once the pilot has been evaluated.
Where a HC420 chart is required, the care provider will now take
responsibility for the recording and administration of
medication/completion of the HC420 . This aligns HCS’ procedure with
that of most other local authorities. In some cases, GP's may be willing
to continue to complete the HC420's so the relevant current can still be
followed.
The HC420 forms have been revised to reflect the changes.
Individuals should be encouraged to self medicate where possible, and
families may assist where this is practical. The care manager assesses which
level of assistance is required and must record this in the care and support
plan. The levels of support defined by the Care Quality Commission are:
Level 1: general support/assisting with medicine
General support is given when the individual takes responsibility for their own
medication. Home care workers work under the direction of the person
receiving the care and must record details of any general support given on the
home care diary sheet.
The support given should be recorded on the care and support plan and may
include some or all of the following:
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Requesting repeat prescriptions from the general practitioner.
Collecting medicines from the community pharmacy/ dispensing general
practitioner surgery.
Disposing of unwanted medicines safely by return to the supplying
pharmacy/ general practitioner practice.
An occasional verbal reminder or prompt from home care staff to an
individual to take their medicines. (A persistent need for reminders may
indicate that the person does not have the ability to take responsibility for
their own medicines and should prompt a review of the care plan).
Physical assistance with manipulation of a container or a monitored dosage
system, for example opening a bottle of liquid medication or popping tablets
out of a blister pack. This is at the request of the individual and where the
home care worker is not required to select the medication.
Level 2: administering medication
The assessment by the care manager may identify that an individual lacks
capacity to manage administering their own medicines and needs assistance.
Administration of medication may include home care workers carrying out
some or all of the following:
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Selecting and preparing medicines for immediate administration.
Selecting and measuring a dose of liquid medication for the individual to take.
Applying a medicated cream/ ointment; inserting drops to ear, nose or eye.
Administering inhaled medication.
Selecting from a monitored dosage system or compliance aid.
Records of all medication administered must be kept on the HC420. See
section 11, record keeping.
Only home care workers who have been trained and assessed as competent
in medication management can be assigned to people who require
administration of their medicines. Home care workers can refuse to administer
medication if they have not received suitable training, or instructions are
unclear and they do not feel competent to do so. This must be reported to
their line manager immediately.
Home care workers should only administer medication from the original
container, dispensed and labelled by a pharmacist or dispensing general
practitioner. This includes pharmacy sealed monitored dosage systems and
compliance aids.
People discharged from hospital may have medication that differs from those
retained in their home prior to admission. The care manager should give
additional advice to home care staff when this occurs, and may need to refer
back to the ward staff or hospital doctor who completed the HC420 or to the
general practitioner. Any previous HC420 should be returned to the provider.
Level 3: administering medication by specialised techniques
In exceptional circumstances some home care workers may undertake
advanced training under the guidance of nursing staff, for example
administration through a Percutaneous Endoscopic Gastrostomy (PEG).
Continuing care funding will normally be required for these services. If the
task is to be delegated, a healthcare professional must train the home care
staff and assess that they are competent to carry out the task. Refresher
training will be required annually and must be certificated or documented.
Home care staff can refuse to assist with the administration of medication by
specialist techniques if they do not feel competent to do so.
Interim procedures for setting up home care support
Interim procedure for setting up home care support with medication:
Home Care provider completing HC420
Care manager :
NB: Clinical responsibility remains with Health. HCS responsibility
is commissioning with care providers.
1.
Complete a universal assessment identifying eligible social care needs
and outcomes and what level of support with medication is required.
Complete a risk assessment and risk management plan
2.
for anyone requiring level 2 support with administration of their
medication. See "controlled drugs" section for extra guidance where
healthcare professional advice is needed.
Carry out a mental capacity assessment
3.
for anyone unable to give consent. Record the reasons that support with
administration of medication is in their best interests.
Complete consent form HCSf 691a
4.
5.
for individuals who can consent to receiving support with their
medication.
HCS care manager to inform Home Care Provider to request
prescription/counterfoil from the practice, allowing 48 hours for collection,
where possible. Care manager to inform GP that the provider will be
requesting this.
Complete the care and support plan
6.
Clearly indicating which level of support with medication is required. Give
detailed instructions re: support required with medication to home care
agency. Instructions on bottles/packing must be followed.
Commission the home care package as usual.
7.
Include delivery and collection of HC420 if necessary.
Care manager to record on ACSIS
8.
that the person is on an HC420 under Factors and Risks, Special
Factors – Health. SCAS worker to complete if commissioning on
behalf of health.
Care manager to inform all those involved
9.
10.
with the care package such as family, district nurse, day care service of
the home carer’s role in administering medicines.
Care manager to send a copy of the care and support plan to the
GP
with the contact numbers of the home care provider.
Send a copy of the care and support plan, risk assessment
11. and risk management plan and consent form to the home care
provider. SCAS to do this for Older People, Physical Disability and
Specialist Mental Health for Older People Teams.
Care manager to complete a review prior to ceasing involvement
and to set a date for a scheduled review. Arrange the review
12. within the timescale specified in the care plan, or when there is a change
in the individual’s circumstances. The need for a HC420 must also be
reviewed and rationale for continuing to be recorded. Update
special factors in ACSIS.
13.
If the review identifies changes in need, send copy of the updated
care plans and risk assessments
to the home care provider and GP.
Home Care Provider to:
Home Care Provider to request prescription/counterfoil from the GP
giving 48hrs for collection, where possible.
14. GP to provide clear, legible prescription/ counterfoil for home
provider collection, with no abbreviations. If medication is to be
given as necessary (PRN) GP to give detailed instructions on
administration.
Record details of all prescribed medicines on the HC420. Include the
name of medicine, form, dosage, frequency, route, indication and any
15. other relevant information. Home Care Provider to ensure robust
arrangements (as per CQC requirements) in place for medication
recording and administration.
16. Complete a new HC420 as required/when complete as step 14. Refer to
relevant Healthcare professional/specialist to update the HC420
chart if specialised medication is prescribed. The ward doctor to
update HC420 on hospital discharge.
Full or discontinued HC420’s to be retained by the provider.
Provider to ensure that the HC420 goes with the person to clinic
appointments and for hospital admissions.
Request a service user review from HCS
17.
if there is a significant change of circumstances or the care package no
longer meets assessed need.
Provide a prescription/counterfoil for repeat prescription in clear,
easy read format for provider collection.
18
GP to inform home care provider where changes to medication and
provide prescription/counterfoil so provider can amend/renew.
Refer to relevant Healthcare professional/specialist to update the HC420
19. if specialised medication is prescribed. Where possible, ensure HC420
accompanies the person to hospital and specialist appointments.
Hospital doctor/relevant healthcare specialist to:
20.
Ensure the HC420 and all new medication is given to the person on
discharge from hospital/following clinic appointments.
Interim Procedure for setting up home care support with medication
where GP completing HC420.
Follow procedure for home care provider completing HC420 if GP no
longer doing this.
Care manager :
NB: Clinical responsibility remains with Health. HCS responsibility is
commissioning with care providers.
Complete a universal assessment i
1.
dentifying eligible social care needs and outcomes and what level of
support with medication is required.
Complete a risk assessment and risk management plan
2.
for anyone requiring level 2 support with administration of their
medication. See "controlled drugs" section for extra guidance where
healthcare professional advice is needed.
Carry out a mental capacity assessment
3.
for anyone unable to give consent. Record the reasons that support with
administration of medication is in their best interests.
Complete consent form HCSf 691a
4.
for individuals who can consent to receiving support with their
medication.
Discuss best option for medication support with GP or multidisciplinary team
5.
. If level 2 support is required gain doctor’s agreement to complete the
medication record HC420. If GP no longer completing HC420’s follow
separate procedure for home care provider completing HC420’s.
Complete the care and support plan
6.
clearly indicating which level of support with medication is required. Give
detailed instructions re: support required with medication to home care
agency. Instructions on bottles/packing must be followed.
Commission the home care package as usual.
7.
Include delivery and collection of HC420 if necessary.
Care manager to record on ACSIS
8.
that the person is on an HC420 under Factors and Risks, Special
Factors – Health.
SCAS worker to complete if commissioning on behalf of health.
Care manager to inform all those involved
9.
10.
with the care package such as family, district nurse, day care service of
the home carer’s role in administering medicines.
Care manager to send a copy of the care and support plan to the
GP
with the contact numbers of the home care provider.
Send a copy of the care and support plan, risk assessment
11.
and risk management plan and consent form to the home care
provider. SCAS to do this for Older People, Physical Disability.
Care manager to complete a review prior to ceasing involvement
and to set a date for a scheduled review. Arrange the review
12. within the timescale specified in the care plan, or when there is a change
in the individual’s circumstances. The need for a HC420 must also be
reviewed and rationale for continuing to be recorded. Update
special factors in ACSIS.
13.
If the review identifies changes in need, send copy of the updated
care plans and risk assessments
to the home care provider and GP.
Home Care provider to:
(where GP continues to complete HC420)
Contact the individual’s general practitioner surgery
14.
to arrange delivery and collection of the completed HC420, where
commissioned.
Ensure full or discontinued HC420’s are returned to the provider
when finished, or replaced after hospital discharge (ward doctor to
complete), and a new HC420 is completed by the general practitioner
when needed.
15.
Where there is a change in provider, new provider to complete a new
HC420. Previous HC420 to be retained by original provider.
Provider to ensure that the HC420 goes with the person to clinic
appointments and for hospital admissions.
Request a service user review
16.
from HCS if there is a significant change of circumstances or the care
package no longer meets assessed need.
GP:
17.
Record details of all prescribed medicines
on the medication record form HC420. This must include the name of
medicine, form, dosage, frequency, route, indication and any other
relevant information.
Home Care Provider to:
Refer to relevant Healthcare professional/specialist if specialised
18. medication is included on the HC420 . Ensure, where possible, HC420
accompanies the person to hospital/specialist appointments.
Hospital doctor/relevant healthcare specialist to:
19.
Ensure the HC420 and all new medication is given to the person on
discharge from hospital/following clinic appointments.
Assessment and care planning
The care manager will carry out an assessment of need in accordance with
eligibility criteria. The following questions may help determine whether people
have capacity to manage their own medicines or what level of support with
medication is required:
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Is the individual confused about when to take their medicines?
Does the individual have other difficulties with their medication?
Is the individual running out of medicines regularly or having too much left?
Has the individual’s condition changed in any way?
Where someone is considered to require level 2 support with administration of
their medication, a risk assessment and risk management plan, form ACSf784
must be completed. This should record how medication risks will be managed,
for example whether pharmacy delivery of medication presents risks, or the
need to store the medicine and/or the HC420 in a secure location, with
particular reference to controlled drugs. The care manager must send a copy
to the home care provider.
Reviews
The care manager should review the care and support plan at least once a
year and should include:
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Reassessment of the level of support required.
Updating of the risk assessment.
Checking the HC420 to see if there are recording omissions or errors.
If so, these must be reported immediately to the home care manager.
If significant changes are made to the care and support plan or risk
assessment, copies should be sent to the home care provider and the general
practitioner.
Capacity and consent
The individual must consent to have home care staff administer medication
and the consent form should be completed where an individual has capacity.
This should be recorded on form ACSf 691a. The care manager should send
a copy of this form to the home care provider when services are
commissioned.
People who lack capacity to manage their own medication may have capacity
to consent to home care staff administering their medication. People will be
assumed to have capacity unless proved otherwise, in line with the principles
of the Mental Capacity Act.
The care manager should carry out a mental capacity assessment if required,
to establish whether the person can give informed consent to receiving
support with their medication. When appropriate, they should seek advice
from the general practitioner/hospital doctor as to whether the person is able
to take responsibility for their own medication. This will be particularly
important where capacity is unclear or there are differing views, such as from
family members.
Where the individual is assessed as lacking mental capacity to give informed
consent to receiving assistance with medication or to managing their own
medication, the reasons and circumstances of this decision must be recorded
in the care and support plan. This record must include the reasons that
support with medication is seen as being in their best interests and who has
made this decision. The general practitioner should then be asked to
complete the medication record form HC420. HC420 Guidance
See Section 7 on roles and responsibilities of the care manager.
See HCS 765 Mental Capacity policy.
See HCS 784 Risk Assessment policy.
Hospital discharge
When someone receiving Level 2 assistance with their medication is admitted
to hospital the home care worker, their manager or a family member should
arrange for the HC420 to be taken to the hospital with the person wherever
possible. Some people will return home with a ‘resumed’ package, that is, the
same care package and medicines as they previously had.
If changes to the medication have been made, the hospital care manager
must ensure the HC420 is updated by the responsible prescriber before the
person is discharged home. They should update the care plan if necessary,
and send a copy to the home care provider.
If the person did not receive assistance with their medication before
admission but it is assessed that they will need support on discharge, their
care and support plan will need to be revised accordingly, and a copy sent to
the home care provider with the commissioning form. Some people may only
need short-term assistance with their medication from a home care worker
until their condition improves. In these situations, through enablement or
intermediate care, support may only be needed for the purposes of
rehabilitation, and to enable the individual to regain their independence.
The need for any assistance with medication must be reassessed at the post
discharge review, to confirm whether or not the person still requires the same
level of support on a longer term basis or could manage with a lower level of
support or independently.
Attending a day centre, short break or respite service
Attending a day service
Where someone receiving level 2 assistance with their medication attends a
day service, the care manager should discuss this with the general
practitioner to see if it is possible to avoid having to administer medication
during the time they are away from home. If this is not possible the person’s
medication should be stored and dispensed from the day service in
accordance with the day service’s policy. Where people attend day services
run by ACS they will have their own record of administering the medication
and the HC420 should not be taken to the day service. Absence due to
attendance at the day centre should be entered onto the HC420 by the home
care worker as the reason why the medication was not administered at home.
For day services run by other agencies the care manager must record on the
care and support plan all the arrangements for transferring any medication
needed during the day to the day service. This may involve the appropriate
medicines and the HC420 accompanying the person to and from the day
service.
Attending a short break or respite service
The care manager must agree the arrangements for medication to be taken to
these services as part of the care planning process and record them in the
care plan.
Roles and responsibilities
Interim Procedure
GP's across Hertfordshire will no longer be completing the HC420
medication record forms.
The CCG’s have commissioned a 6 month pilot from July 2014 to trial a
pharmacy model where the pharmacist is responsible for the production,
maintenance and evaluation of the MAR (Medicines Administration
Record). This will be piloted for 6 months from July 2014 in the
Stevenage; Bushey and Watford areas. HCS will evaluate the service
and look to expand this across Hertfordshire. You will be kept informed
re; progress.
As an interim measure, the following procedure has been agreed and
issued with regards to the completion of the HC420’s. Please note that
this may mean, in some areas, this differs from current procedures. The
whole document will be reviewed once the pilot has been evaluated.
Where a HC420 chart is required, the care provider will now take
responsibility for the recording and administration of
medication/completion of the HC420 . This aligns HCS’ procedure with
that of most other local authorities. In some cases, GP's may be willing
to continue to complete the HC420's so the relevant current can still be
followed.
The HC420 forms have been revised to reflect the changes.
Roles and responsibilities of care manager/care coordinator including
those in hospital teams
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Carry out an assessment of need identifying eligible social care needs
and outcomes.
Obtain and record the person’s consent for assistance with their
medication.
Agree and record on the care and support plan which level of support
is required with medication, as described in section 3, levels of medication
support.
If an individual is unable to communicate their consent then the
reasons that support with medication is seen as being in their best interests
must be recorded.
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Complete a risk assessment, with general practitioner input when
appropriate, identifying the level of support required and any additional
safeguards such as the secure storage of medication.
Carry out a mental capacity assessment if required. If necessary seek
advice from the general practitioner /hospital doctor as to whether the client is
able to take responsibility for self medication.
Discuss with the general practitioner whether there are options for
dispensing the medication differently in order to support the person’s
independence wherever possible.
Obtain the general practitioner’s agreement to complete the medication
record HC420 and discuss the number and pattern of any existing home care
visits, to avoid increasing ‘medication only’ visits if possible.
Send the general practitioner a copy of the care and support plan.
Record on the care and support plan details of all the support required,
including:
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Arrangements for ordering prescriptions.
Arrangements for collection of medicines from the pharmacy.
Whether secure storage of medication is required.
Commission the care package with the appropriate allocation of time
for all identified tasks to be completed.
Ensure that all those who may be involved with the care package such
as family, district nurse, general practitioner, day care service, are aware of
the home care worker’s role in administering medicines and understand the
procedures.
Ensure that any agreements for family members to assist the individual
with their medication are clearly recorded in the care and support plan and
home care service plan. Family input should not be included on the HC420.
Inform the general practitioner of the contact numbers of the care
provider in case of any urgent communications regarding the person’s
medication.
Ensure that a review is completed prior to ceasing involvement and
that a date is set for a scheduled review. Reviews should be arranged
whenever there is a significant change in the individual’s circumstances and
after discharge from hospital, ensuring the HC420 reflects any changes in
prescribing when applicable. Where there is no change reviews must take
place within the timescales specified in the care plan, and at least once a year.
Roles and responsibilities of home care manager
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Ensure that all home care staff follow this policy and have appropriate training
to meet its requirements.
Ensure that home care workers are not asked to administer medication
without having had appropriate training and an assessment of their
competency.
On receipt of the commissioning form ensure that the guidelines and
procedures for administering medicines are followed.
Ensure that the organisation has an adequate supply of medication record
forms HC420.
Where commissioned, contact the individual’s general practitioner surgery to
arrange delivery and collection of the completed HC420.
Ensure care packages are restarted or updated after hospital discharge,
according to the care and support plan.
Ensure medication and medication record form HC420 are stored in a safe
place in the individual’s home, as recorded in the risk assessment.
Ensure there are clear arrangements for the collection of prescriptions, where
this has been commissioned.
Seek clarification from general practitioner or pharmacist if in any doubt about
any instructions.
Contact a general practitioner or nurse without delay if home carer reports any
concerns about the medication or health of an individual.
Notify the general practitioner if medication has not been given.
Keep information about the individual’s medicines and treatment confidential,
in accordance with the provider’s confidentiality policy.
Monitor home carer workers’ work and ensure that procedures are followed.
Ensure completed or discontinued medication record forms HC420 are
returned to the provider when finished, and a new HC420 is completed by the
general practitioner when needed.
Roles and responsibilities of home care workers
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Read and understand the medication policy and procedures.
Attend induction and training and be assessed as competent to administer
medication.
Carry out the level of assistance required by the individual as defined in their
care and support plan.
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Preserve the dignity and respect the wishes of the indiviudal, including cultural
practices, when assisting with medication.
Have a clear understanding of what they can and cannot do to assist people.
Record all medication given or missed on the HC420 and record additional
information on the diary sheet.
Report any refusal of medication or side effects to their line manager.
Discuss any other queries or concerns with their line manager.
See next chapter, essential information for home carers assisting and
administering medication.
Roles and responsibilities of general practitioners
Please note the general practitioner may in practice delegate the task of
completing the HC420 medication form to their representative.
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Advise, if requested, on whether the individual is able to take responsibility for
self medication or just requires general support.
Consider whether there are alternatives to requiring a home carer to
administer the medication, as part of care plan discussions with the care
manager.
Consider dosage intervals that fit with existing number of home care visits
wherever possible.
Authorise and record relevant details of all prescribed medicines on the
medication record form HC420. This must include the name of medicine, form,
dosage, frequency, route, indication and other relevant information such as ‘to
be taken after food’.
Ensure the entry is signed and dated by the prescriber.
Home care workers cannot administer any medication not recorded on the
HC420 by the general practitioner, hospital doctor or nurse prescriber.
Record on the person’s medical notes that they have an HC420.
Ensure that all hand written entries on the HC420 are legible, unambiguous,
and indelible. Abbreviations should not be used.
Avoid using terms which are difficult to understand or interpret by home care
workers such as ‘as required’ or suggesting variable dosage such as ‘take
one or two tablets’. Home care staff are not clinically trained and may not
have visited the person before.
Confirm any changes or discontinued medication by drawing a line through
the previous entry on the medication record form HC420 and make a new
entry. Ensure any amendments are made very clearly and that the directions
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can not be misinterpreted, or if followed specifically, cannot result in harm to
the patient.
At home visits, record any changes clearly on their patient's HC420 which
should be kept in an accessible place with the care plan. If an HC420 is
brought to the surgery by a home care worker, nurse or family member for
updating, this should be done as promptly as possible.
After hospital discharge, update the HC420 with any changes of medication
suggested by hospital doctors as promptly as possible.
Roles and responsibilities of district nurses
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Show home care workers how to assist individuals with specialist techniques
or devices such as nebulisers, suction devices, or oxygen cylinders where
necessary. The care manager may have to request a district nurse referral if
they are not already involved.
Train home care workers to use other specialist methods such as
administration though a Percutaneous Endoscopic Gastrostomy (PEG) where
necessary, as agreed in the care plan.
Give home care workers clear written instructions on using the particular
device or technique, clarifying or simplifying manufacturer’s instructions where
appropriate.
Assess and record that individual home care workers are competent to carry
out these specialist tasks in level 3 support. Offer refresher training annually
and reassess home care workers’ competence accordingly.
Warfarin – to monitor the home care workers within a framework of regular
support and review only after a stable fixed dosage pattern has been
established for a period of two months, and as agreed in the care plan.
Essential information for home care workers assisting and
Home care workers may only assist with the administration of medication
when appropriate training has been received.
See section 12, training and competencies for home care staff
Assisting and administration of medication for the purposes of these
guidelines includes the following:
a) Reminding (prompting) the person to take their medication, and observing
that they have taken it.
b) When this is not possible, helping the person to take medication from the
container and observing that they have taken the medication themselves.
c) When a) and b) are not feasible, removing the dose of medication from the
container and assisting the person to take it.
d) Where the person has been assessed as needing Level 2 support the
person should be assisted with the administration of medication.
Home care workers must follow this procedure for people on level 2 support
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Take medication and medication record form HC420 from storage point.
Check medication record form HC420 relates to person.
Check special notes section on the form, and any other notes such as diary
sheets/daily reports that may relate to medication.
Check whether any short term medication has. been prescribed.
Locate the appropriate date column
Ensure medicine has not already been given.
Select medication, checking label on the container against the medication
record form HC420.
Ensure understanding of:
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The correct dosage and form to be given.
How often it is to be given.
How it is to be given as described in the route.
Other directions such as ‘after food’.
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Check for any discrepancies between the label on the medicine and the
HC420 before administration.
Administer medicines and then immediately tick and initial the HC420 clearly
in the appropriate box.
The reason for any non administration should be immediately recorded on the
medication record form HC420, using the keys indicated, as well as in the
person’s diary sheets/daily reports.
Do not administer medicine to a person who clearly refuses it.
Keep medicines in their original container and never alter label.
Inform the home care manager, general practitioner or nurse if there is any
difficulty, uncertainty, or incident arising out of the administration of medicine.
Notify the home care manager when medication record form HC420 is
nearing completion.
Only give medicines by mouth or external application unless specific training
has been provided by the general practitioner or nurse.
Home care workers may refuse to administer medication if they have not
received suitable training, or instructions are unclear, or they do not feel
competent to do so.
General principles for level 2 administration of medication
Home care workers may assist an individual to take medication which has
been prescribed by their general practitioner, hospital doctor or nurse
prescriber.
The prescribed medication must be entered onto the HC420 by a doctor or
prescriber.
Home care workers must only administer medication from medicine
containers supplied by a community pharmacy, hospital pharmacy or
dispensing doctor practice.
Medication must only be administered if the container is clearly labelled with
the person’s name, the name of the drug(s) dosage and directions. Any
discrepancies with the HC420 must be reported to their manager.
Home care workers should follow carefully the dosage instructions and any
special instructions on the label of the medication, such as ensuring the
medication is taken before or after a meal.
If medication is labelled with imprecise or ambiguous directions, e.g. ‘take as
directed’, ‘take as before’, ‘apply to the affected part’, or with unclear
abbreviations, the home care workers must seek clarification from their line
manager who must ensure clear written directions are obtained.
If the label becomes detached from the container, is illegible, or has been
altered, medication must not be administered. Advice should be sought from
the home care manager who should seek further advice where necessary.
No more than 28 days supply of medicines, including those on repeat
prescriptions should normally be requested for an individual at any one time.
Medicines have an expiry (use by) date. The expiry date must be checked
before each administration of the medicine to ensure that the medicine may
still be used.
Some medication causes side effects and the home care worker should be
alert to this possibility and report any concerns to their manager. In an
emergency they should contact the general practitioner, pharmacist, or NHS
Direct.
The home care worker must contact their line manager for advice in the event
of an individual refusing to take prescribed medication. This should be
recorded on the HC420.
Prescribed medication
All home care workers who have undertaken the appropriate training on the
management of medicines may provide assistance with:
Medication taken by mouth (oral preparations) e.g. tablets, capsules and oral
liquids, and
Medication applied externally to the skin e.g. ointments, creams, lotions.
Medication such as eye, ear or nose drops, topical patches and inhalers.
Oral medication
Medication should not be handled, and solid dose forms e.g. tablets and
capsules should be passed to the person on a spoon. Where the home care
worker has to place the dose in the person’s mouth, they should wear
disposable gloves.
Tablets should never be crushed, nor capsules opened, without the explicit
instruction of the prescriber and only when recorded on the pharmacy label
and then a proper pill crusher must be used. Tablets must never be cut or
split and if smaller doses have been prescribed the pharmacist should be
asked to do this.
Tablets and capsules are best taken with water. Some medication must be
dissolved or dispersed in water before administration. This will be indicated on
the label.
Doses of liquid oral medication must be measured using a 5ml medicine
spoon, a graduated medicine measure or an oral syringe supplied by the
pharmacist. Home care workers should contact their line manager if the
individual is experiencing difficulties with liquid oral medicines.
External medication
Creams, ointments, and lotions should only be applied by home care workers
where the skin area to be treated is unbroken. They should ensure the skin
area is clean, and spread over the affected area gently. They must follow
printed information on the dispensing label such as ‘apply thinly’.
Home care workers must wear disposable gloves when applying external
medication and must contact their line manager if they have concerns
regarding the application of external preparations.
Other medicines
Assistance with the administration of drops or other preparations such as
ointment for instillation into the eye, ear or nose, and medication in patches to
be applied to the skin (transdermal patches) may only be given after specific
written instructions from the home care manager. Where necessary the home
care worker will receive specific training in the administration of unusual
medications or preparations.
The date of opening of eye, ear or nose drops must be written on the label
and they should not be used if they have been open for more than 28 days. If
no opening date has been recorded the 28 days must be counted from the
date on the pharmacy label. If under 28 days the drops are safe to use. If the
date is more than 28 days ago do not use. Drops should not be applied
immediately on removal from the fridge.
Assistance with nebulisers, inhaler devices, and oxygen cylinders must only
be given by home care workers who have received instructions on the use of
the particular device.
Where there are specific needs or risks for an individual around a particular
condition, these must be fully documented in the care and support plan.
Warfarin tablets
Adult Care Services will not commission home care workers to administer
warfarin for new service users until a stable fixed dosage pattern has been
established for a period of two months by the district nurse. If the dosage
pattern is not stable, but subject to regular changes, then the responsibility for
administration will rest with the district nursing service and home care workers
would not be expected to administer.
If a stable dosage pattern has been established then home care workers may
administer warfarin, but within a framework of support and regular review
agreed with the district nursing service and recorded in the care plan.
Warfarin increases an individual’s likelihood of bleeding. If an individual taking
warfarin develops any bruising or bleeding their general practitioner or NHS
Direct should be contacted for advice before administering a dose of Warfarin.
As required medication, also known as PRN
Most medication will be prescribed for administration on a regular basis.
Some treatments may be prescribed on an ‘as required’ or PRN basis for
people on Level 1 assistance.
‘As required’ medication should not normally be included on the HC420 for
people on Level 2 support as they will be unable to make informed decisions
about their medication. If a general practitioner does prescribe PRN for
someone on level 2 support, the circumstances must be recorded in the risk
assessment.
Regular requests for medication not on the HC420 should be referred back to
the manager who may need to request that the general practitioner carries out
a medication review.
Controlled drugs
There is no legal requirement for Controlled Drugs to be treated differently
from other prescribed medicines when prescribed and administered for
administration in an individual’s own home. Controlled Drugs such as
morphine are usually prescribed to treat severe pain. The doctor should
specify the dose and maximum frequency. If these drugs are required on an
‘as required’ basis by people needing assistance (Level 1) additional written
guidance may be needed for home care workers. People who lack capacity
and are on Level 2 can only receive administered measured doses, and
cannot be given drugs on an ‘as required basis’. The risk assessment may
require the secure storage of such medication. Home care workers must refer
any requests about additional pain relief to their manager.
Medications outside the scope of this policy
The following medications must NOT be administered by home care workers:
- Injections.
- Suppositories.
- Pessaries.
- Enemas.
- Rectal creams.
- Vaginal creams.
- The application of dressings involving wound care.
- The application of medication to broken skin.
The administration of these medications is the responsibility of a health care
professional such as a district nurse. In some circumstances home care
workers will have undertaken advanced training to enable them to undertake
some of the above tasks under the guidance of nursing staff. The health care
professional remains responsible for the monitoring of such assistance with
health care tasks, and in circumstances where the individual meets the criteria
for continuing care, the Primary Care Trust will need to fund this support.
Non-prescribed medicines and remedies
Individuals receiving Level 1 support may ask home care workers to assist
with the purchasing or the taking of non-prescribed medication. This could
include paracetamol, cold remedies, and medication for constipation or herbal
remedies. This should be avoided where possible. Further advice should be
sought when an individual is taking prescribed medication before purchasing
and non-prescribed medication. If there are any concerns the home care
worker should seek advice from the home care manager, who may seek
advice from the general practitioner or pharmacist. Details of any nonprescribed medication given with the assistance of the home care worker
must be recorded on the individual’s diary sheets.
Home care workers must not offer advice on non-prescribed medicines or
remedies. It may be dangerous to do so. The individual may be allergic to the
treatment or be taking other medicine that may result in harm to themselves.
Where the individual is on Level 2 support and lacks capacity to authorise
assistance with their medication, but is requesting non prescribed medicines
the care manager should request a review of their medications by the general
practitioner. Non-prescribed medicines should not be administered by home
care workers unless clear guidance has been given.
Food supplements
Food supplements should be treated as any other special diet, that is, the
instructions should be clearly noted in the care/service plan and should be
followed by the home care worker. Details should be recorded in the
individual’s dairy sheets. Where food supplements have been prescribed by a
doctor they should be recorded on the HC420. If these are not being taken on
a regular basis, this should be reported to the home care manager.
Monitored dosage systems and compliance aids
Pharmacy sealed compliance aids can be used for tablets and capsules and
may assist some individuals, who only need Level 1 general support with their
medication to maintain their independence. There may be a cost involved for
the individual as the NHS does not automatically fund these systems though
individuals may be eligible for support needed to manage medicines
themselves, under the Disability Discrimination Act.
A number of medicines cannot be placed in these aids including medicines
sensitive to moisture or light or that may be harmful when handled. Liquid
medicines, creams, eye drops and inhalers must be supplied in their individual
containers.
People who lack capacity to manage their own medication and are on Level 2
support with an HC420 should not need a monitored dosage system. This
would entail two systems of assistance having to be in place, which would
involve unnecessary additional costs and risks. Such compliance aids may
not be suitable for all of the patient’s medication, such as creams and liquid
medicines.
However, where a family member or general practitioner requests this and it is
agreed to be necessary, or the family wish to fund this, the home care worker
must ensure that:
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The correct blister is used.
The blister pack has not been tampered with.
The contents of the blister pack are fully emptied.
Care is taken to ensure the medication is not dropped, damaged or crushed.
A record of the blister administered is made on the HC420.
Home care workers must not administer any medication from monitored
dosage systems or compliance aids made up by anyone other than a
Pharmacist. Home care workers must not re-package medicines into a
compliance aid, or use one made up by a family member or friends of the
individual.
Variable dosage schedules
Some medication is prescribed on a reducing or variable dosage regime.
These are used to increase or reduce the dose of a drug over a defined
period of time. Additional information about this should be shown on the label
or provided through additional instructions which must always be referred to.
Dosing intervals
Individuals may need assistance with the administration of medication at
specific time intervals. In these cases the care manager completing the
assessment should check with the general practitioner or pharmacist and
home care provider to see if the dosing schedule of the medications can be
realigned and co-ordinated within the existing patterns of home care visits. If
the dosing intervals are an essential component of treatment, for example in a
6 hourly regime for antibiotic treatment, or evening doses, and the service
provided does not cover these requirements, the care manager should
increase the care package accordingly.
Storage, supply and disposal of medication
Storage of medicines
Medicines must be stored to ensure they cannot accidentally be mixed up with
other people’s medicines and out of the reach of children. They should be
kept away from damp and heat sources. All prescription medicines must be
provided and contained within the original pharmacy produced labelled
packaging or compliance aid. They must be readily accessible to all home
care workers.
Certain medicines have defined storage needs that must be followed.
Medicines requiring refrigerated storage should be kept away from food.
The need to store medicines in a locked container will only occur where the
care manager has assessed that this is required to protect the health and
safety of the individual. This decision should be taken following discussion
with family members and health care professionals and recorded in the risk
assessment. It should be considered when Controlled Drugs are to be
administered. If the home care worker feels that there is a genuine and urgent
risk to the person’s wellbeing, medication may be placed in a location where
the person cannot find it on a temporary basis. This should be reported
promptly to the home care manager who must ensure that other home care
staff are aware of the situation, and refer the person for an urgent review of
their care and support plan. Updated information must then be transferred on
to the home care service plan which is kept in the person’s home.
Supply of medicines
The arrangements for the ordering, collection and dispensing of prescriptions
should be recorded on the individual’s care and support plan. Some
pharmacists will offer a prescription collection (from the general practitioner
practice) service and a delivery service for dispensed prescriptions. The care
manager will need to review this arrangement if it could present any risks to
the individual.
Obtaining repeat supplies of medicines will need a repeat prescription request
to be taken to the general practitioner surgery. Assistance with this should be
documented in the care and support plan.
Disposal of medicines
The service user or informal carer should be encouraged to return unused or
unwanted medicines to a pharmacy. They should not add them to their
household waste or flush them away with the sewage.
Where there is no informal carer such as a family member who can be
responsible for the prompt return of unwanted medicines the home care
worker must obtain approval of their line manager to return the medicines to
the pharmacy. They should request a receipt to keep on the home care file.
The home care manager may also need to notify the general practitioner if
medicines are not being used. The names and quantities of all medicines
removed should be recorded, and a copy retained in the person’s care notes.
Record keeping
Interim Procedure
GP's across Hertfordshire will no longer be completing the HC420
medication record forms.
The CCG’s have commissioned a 6 month pilot from July 2014 to trial a
pharmacy model where the pharmacist is responsible for the production,
maintenance and evaluation of the MAR (Medicines Administration
Record). This will be piloted for 6 months from July 2014 in the
Stevenage; Bushey and Watford areas. HCS will evaluate the service
and look to expand this across Hertfordshire. You will be kept informed
re; progress.
As an interim measure, the following procedure has been agreed and
issued with regards to the completion of the HC420’s. Please note that
this may mean, in some areas, this differs from current procedures. The
whole document will be reviewed once the pilot has been evaluated.
Where a HC420 chart is required, the care provider will now take
responsibility for the recording and administration of
medication/completion of the HC420 . This aligns HCS’ procedure with
that of most other local authorities. In some cases, GP's may be willing
to continue to complete the HC420's so the relevant current can still be
followed.
The HC420 forms have been revised to reflect the changes.
Instructions for recording on the HC420
For people on Level 2 support, the home medication record, the HC420 will
be kept in the individual’s home, with a copy of their care and support plan, in
a safe and accessible place.
The names of all home care workers visiting an individual, together with their
signatures and initials, must be recorded on the home care providers’ files.
All assistance with administering medication must be initialled at the time of
the visit. The home care worker must record on the HC420 all medicines
given, missed or refused, for both short term and long term medication. They
must record the time of their visit and their full name on the diary sheet.
Home care workers can only carry out this service once they have received
training and been assessed as competent. They must never change or
tamper with the instructions written on the HC420. They can only use an
HC420 that has been filled in by the general practitioner, hospital doctor or
nurse prescriber.
Home care workers should check that dosage timings are clearly indicated.
The words ‘as required’ or ‘as directed’ should not appear and the home care
manager should be contacted with any concerns or questions.
Home care workers should administer the medicines shown on the HC420
using the checks below for EACH MEDICINE:
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Check it is the correct medicine, form, dose and time of day.
Check the record and make sure the medication has not already been given.
Select the medicine and confirm it has not exceeded its expiry date by
checking the date on the dispensing label.
Check the name of the service user, the name of the medicine and the
instructions on the bottle or box are the same as on the HC420 – if not, do not
give it.
Give the medicine to the person.
If giving orally, check the dose has been swallowed.
Enter your initials clearly on the correct date and time immediately after it has
been administered, to show you have given it.
If the medicine is not given enter the code in the box:
R = REFUSAL
A = ABSENCE OF PERSON
D = DISCREPANCY, including any missing medication
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If a compliance aid is used, initial once for the blister used
A single spoilt or refused dose should not be returned to the container.
Record more detailed information about why medication has been missed on
the person’s home care service plan.
Home care workers must only record assistance given by themselves.
Training and competencies for home care staff
Training
ACS work with home care providers to ensure staff training meets Care
Quality Commission minimum standards which are:
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How to prepare the correct dose of medication for ingestion or application.
How to administer medication that is not given by invasive
techniques, including tablets, capsules and liquid medicines given by mouth;
ear, eye and nasal drops; inhalers; and external applications.
The responsibility of the care worker to ensure that medicines are only
administered to the person for whom they were prescribed, given in the right
(prescribed) dose, at the right time by the right method/route.
Checking that the medication ‘use by’ date has not expired.
Checking that the person has not already been given the medication by
anyone else, including a relative or care worker from another agency.
Recognising and reporting possible side effects.
Reporting refusals and medication errors.
How a care worker should assist with medicines prescribed ‘as required’ for
people on level 1 support, for example, pain killers, or laxatives.
What care workers should do when people request non-prescribed medicines.
Understanding the service provider’s policy for record keeping.
Training should also cover the supply, safe storage and disposal of medicines.
Also See: Accountability, Responsibility And Confidentiality - The Handling Of
Medicines In Social Care (Royal Pharmaceutical Society of Great Britain) and
Professional Advice – The Administration of Medicines in Social Care (Care
Quality Commission).
Competencies required
See the checklist of competencies in the next section.
Assessment of competencies
Each home care provider must establish a formal means to assess whether
the home care worker is sufficiently competent in medication administration
before being assigned the task. This will include the observation and
supervision of staff administering different medicines and recording. An
agreed method of approving assessors is required for each provider.
All competencies must be observed in order to assess the home care worker
and this may involve practice sessions.
The home care worker must demonstrate the competency as it is described in
the assessment criteria.
Once all the competencies have been performed correctly, the assessor
should provide a signed record that the worker has been assessed as
competent to administer medication.
If the competency has not been performed correctly, the assessor should
show the home care worker how to perform the competency, check
understanding and suggest a new time/date for reassessing the competency.
Competency in administration of medicines should be assessed on an annual
basis and a record held in the worker’s personal file and unit training records.
Legislation and related policy framework
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National Minimum Standards for Domiciliary Care (CQC).
Skills for Care – Knowledge Set for Medication.
The Handling of Medicines in Social Care Royal Pharmaceutical Society of
Great Britain (2007).
Mental Capacity Act (2005).
Relevant Adult Care Services policies and procedures:
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ACS 765 Mental capacity.
ACS 784 Risk assessment and risk management policy.
ACS 745 Assessment and care management.
Glossary
ADMINISTER
The act of giving medicines to an individual for immediate consumption.
ASSESSMENT
The process for identifying and recording the needs and risks for an individual
so that appropriate action can be planned.
BLISTER PACK
Medication in sealed compartments prepared by pharmacists as compliance
aids.
CARE AND SUPPORT PLAN
An agreed record which sets out the outcomes for any help required, with
details of services to be provided, who will be responsible for arranging them
and a review date.
CARE MANAGER
The worker responsible for carrying out the assessment, care planning and
review of an individual’s care needs – usually a social worker, care
coordinator or community care officer.
CARE PACKAGE
The combination of services agreed in order to meet the individual’s assessed
needs
COMPLIANCE AID
A system which helps the individual to take their medication. May also be
known as a monitored dosage system.
DIARY SHEETS
The daily record for home carers to complete during their visits to an
individual.
DOSETTE BOX
One type of monitored dosage systems/compliance aid
HC420
The chart used for home care workers to record all administration or refusal of
medicines.
INDICATION
The medical condition for which the medicine is prescribed.
INDIVIDUAL
The person receiving support, previously referred to as the service user.
MEDICATION
The terms drug, medicine and medication are used interchangeably.
MONITORED DOSAGE SYSTEM
A system or device which separates doses to help an individual manage their
medication. It must be prepared and sealed by a pharmacist and is only
suitable for certain drugs. May also known as a compliance aid.
NOMAD
One brand of monitored dosage systems/compliance aid.
PRESCRIBING
The act of recommending or ordering the use of a medicine or a remedy by an
individual.
RISK ASSESSMENT
A systematic process for checking risks and hazards for individuals and how
best to manage these safely.