In March 2014 NICE issued its first social care guidance on managing medicines in care homes.
The purpose of this guidance was to provide recommendations for good practice in the processes employed to manage medicines in care homes. At Numark we have incorporated this best practice for medicines management into our Medicines Management in Care Homes Training.
As a follow up to their guidelines, this month NICE issued its ‘Quality Standard’ for managing medicines in care homes. This standard emphasises key areas of the NICE guidance to focus on. NICE anticipates that publication of this quality standard will have a positive impact on medicines management in care homes, including:
- a reduced number of adverse events associated with medications errors.
- improved quality of life for care home residents.
- improved confidence in the delivery of care by family and carers.
- individualised care with medicines.
- a reduction in medication errors.
The quality standard focuses on six key areas of medicines management. The quality statements are:
- People who transfer into a care home have their medicines listed by the care home on the day that they transfer (medicines reconciliation).
- Providers of health or social care services send a discharge summary, including details of the person’s current medicines, with a person who transfers to or from a care home.
- People who live in care homes are supported to self-administer their medicines if they wish to and it does not put them or others at risk.
- Prescribers’ responsible for people who live in care homes provide comprehensive instructions for using and monitoring all newly prescribed medicines.
- People who live in care homes have medication reviews undertaken by a multidisciplinary team.
- Adults who live in care homes and have been assessed as lacking capacity are only administered medicine covertly if a management plan is agreed after a best interests meeting.
1. People who transfer into a care home have their medicines listed by the care home on the day that they transfer.
Accurate records of medication are essential to ensure that care home residents receive the right medicine at the right time. Accurate and efficient record keeping ensures that residents experience continuity of care with appropriate clinical decisions being made and effective communication between health and social care teams.
It is important that accurate lists of medication are available as soon as possible for care home residents after first arrival at the home or when moving back to the home after a hospital stay where their medication was changed. Ideally medicines reconciliation should happen before residents enter the home. NICE guidance advises that this process of reconciliation should involve a pharmacist at some stage in the process.
2. Providers of health or social care services send a discharge summary, including details of the person’s current medicines, with a person who transfers to or from a care home.
All healthcare providers should ensure that comprehensive and accurate records of a resident’s medicine are sent with the resident when they are transferred between care settings. Efficient transfer of information is a key factor in reducing the risk of medication errors and also ensuring continuity of care for the resident.
Care providers are advised to refer to the Royal Pharmaceutical Society report on “Keeping patients safe when they transfer between care providers - getting the medicines right”. This includes guidance on the recommended core content of medicines records. All care homes should have procedures in place to enable them to share accurate information about a resident’s medicines.
3. People who live in care homes are supported to self-administer their medicines if they wish to and it does not put them or others at risk.
It is important that residents in care homes retain as much independence as possible and that they have as much involvement in taking their medicines as possible. NICE guidelines state that every resident, on arrival at a care home, should be presumed able to look after and manage their own medicines unless indicated otherwise.
Each resident should be risk assessed to identify the level of support that they require to enable them to administer their own medication. The assessment will also confirm whether they would pose a risk to themselves or other residents if they were to self-administer their medicines.
Risk assessments should consider the following:
- Resident choice.
- Risk posed to the resident or other residents from self-administration.
- Whether the resident can take the correct dose of their medicines at the right time in the right way.
- How often the assessment should be reviewed.
- How the medicines will be stored.
- Responsibility of the care home staff.
It is important that anything that affects a patient’s ability to manage their own medicines is considered and potential barriers to self-administration are identified and taken into account during the risk assessment.
4. Prescribers responsible for people who live in care homes provide comprehensive instructions for using and monitoring all newly prescribed medicines.
The care home use of medicine study (CHUMS 2009) reported that about a third of care home residents experienced at least one prescribing error. These errors were most commonly attributed to incomplete information being included on the prescription.
In order to reduce the risk of medicines errors, prescribers should ensure that they provide clear instructions on when and how medicines should be administered. This is particularly important for medicines prescribed as “when required” or with a variable dose.
Prescribers should also ensure that care providers understand:
- any monitoring or tests that the resident may require.
- the maximum amount of medicine that can be taken in a day.
- when and how the medicine should be taken.
- the effect the medicine is expected to have.
- the anticipated duration of treatment.
- how long the medicine will take to work.
- the term “as directed” should be avoided on prescriptions.
Clear prescribing systems will reduce the risk of residents experiencing medication errors through omission of medicines or incorrect dosages.
5. People who live in care homes have medication reviews undertaken by a multi-disciplinary team.
Care home residents are more likely to suffer from multiple and complex health problems and as a consequence have a higher incidence of polypharmacy. This increases the risk of medication side effects and drug interactions.
Care home residents may also be less likely to report adverse effects which will only become apparent when they have caused a significant health problem. Proactive and planned medication reviews will assist in the identification of medication issues before they cause harm.
Health and social care practitioners, such as GPs and care home managers, should make arrangements for each care home resident taking medication to have medication reviews. The frequency of this review will be determined by the health and care needs of the resident with the resident’s safety being the most important consideration when determining the review frequency.
The interval between reviews should not exceed one year. The review should involve a multi-disciplinary team including a pharmacist, specialist nurse, GP, care home staff, practice nurse or social care practitioner. The multi-disciplinary team should agree and document the roles and responsibilities of each team member and how they work together taking into account their individual clinical experience and skill.
6. Adults who live in care homes and have been assessed as lacking capacity are only administered medicine covertly if a management plan is agreed after a best interests meeting.
Covert administration is where medication is administered in a disguised form without the resident knowing. This form of administration should only be used in exceptional circumstances. Covert administration should only be considered after the appropriate legal assessments, including an assessment of the resident’s mental capacity, have been made and the best interests of the patient considered.
It is important that the care home has a covert medicines administration policy and that this is followed to protect both the patient receiving the medication and the care home staff involved in administration. The decision over how to administer the medication should always involve a pharmacist to ensure that it will not adversely affect the medicine’s pharmacokinetics.
To support our members when providing advice on the suitability of covert administration, we have produced a Pharmacy Excellence module and an additional resource to support the decision making process.
The resource forms a checklist of the questions or processes that should occur prior to covert administration. It also details the pharmaceutical aspects that pharmacists are advised to consider. The document can also act as an audit trail of advice provided, confirming the appropriateness of the method of administration.
So what can pharmacists do to support these standards?
Pharmacists have a key role in enabling care homes to satisfy each of these quality standards. This will ensure the safe and effective management of medication within the home.
Pharmacists should be prepared to assist or advise care homes on the process of reconciling medication during or following the transfer of care. This would ensure that residents leave their current home and arrive at their new home with an accurate and up to date record of their current medication, satisfying standards one and two.
This process may be further supported by provision of advanced services such as Medicines Use Reviews or New Medicines Service (or regional equivalent) within the care home. Permission from the local health authority would be required to enable pharmacists to provide these services at the care home. Pharmacists may also be asked to participate in the multi-disciplinary medication review specified in standard five.
A pharmacist’s understanding of the impact of manipulating a solid dosage form is essential to ensure that any proposed method of covert administration will not adversely affect the pharmacokinetics of each medication. Pharmacists are ideally placed to support standard six.
Perhaps the biggest impact a pharmacist can have is to provide training to care home staff on the principles of medicines management.
Numark Medicines Management in Care Homes training
As a consequence of NICE guidance and quality standards pharmacists may find that care homes are requesting increasing amount of medicines related information and support including:
- reviewing and reconciling medicines.
- advice on reducing or identifying side effects.
- methods of covertly administering medicines after an appropriate multi-disciplinary review.
- assessment of a resident’s ability to self-medicate or advising on treatment options to allow residents to self-administer their medication.
Numark Medicines Management in Care Homes training is accredited by the Royal Pharmaceutical Society and is compliant with both NICE guidance and quality standards.
The training comprises three modules that cover all aspects of medicines management within the care home, including ordering, receiving, storing, administering and disposing of medication. It also considers specific areas such as covert administration, refused or spoilt medication, homely remedies, medicines administration errors and safeguarding concerns.
The training assessment process comprises a theory test and a workplace competency assessment evaluated by the care home manager or nominated deputy. This workplace competency enables care home management to demonstrate that their staff have the required level of practical competency required to safely administer medicines within the care home.
Our Care Homes Trainer Manual with A3 presenter pack costs £100 per pack.
Should you have any queries with regards to this or the care homes resource, please call Numark Information Services on 0800 783 5709.*
*Calls may be recorded for training and quality control purposes.