Practical advice for managing medicines in care homes (5 minute read)

November 14, 2019 By Steve Turner

The Patients Association has recently published a ‘Care Home Charter’ for medicines (link: http://bit.ly/2p1H76b). A key theme of the charter is medicines safety, which is the focus of this opinion piece.

Ensuring your Medicines Policy is accessible and can be used for training.

It’s worth considering how your policy links to staff training, and how accessible user-friendly it is. Are procedures outlined clearly in the policy? Do they link to Standard Operating Procedures [SOPs] and to competency assessments? Are they updated as the result of incidents and near-misses, and do you use checklists to make them easy to read, follow and audit?

Using this simple checklist can help ensure your policies are up-to-date, accessible and relevant, and don’t just sit on a shelf.

Click here for more information on the Care Right Now Speak Up For Learning approach to change.

Ensuring residents have at least 1 multidisciplinary medication review per year.

There is increasing help available from Clinical Commissioning Group Medicines Management Teams and Specialist Clinicians in this area.

These baseline actions can also help the review process:

This includes our useful resource page www.medsinfo.guru

Ensuring you have safe systems for administering and recording medicines.

It is vital that you have an accurate, accessible, legible and auditable system for medicines administration.

There has been a recent move by some of Pharmacies to change residential homes from Monitored Dose Systems [MDS] (also called blister packs) back to Original Pack Dispensing [OPD]. The reason for this, often given, is to improve safety. It is sometimes incorrectly implied that ‘guidelines’ are driving this move back to original pack dispensing, even bizarrely that OPD can help prevent polypharmacy & reduce medicines waste.

I have not been able to find any evidence that OPD is safer than MDS. The related NICE guidelines, quality standards and the CQC report ‘Medicines in Health and Social Care’ do not state this.

What’s important is that the home uses the safest system of delivering the medicines to the residents, considering the resident’s wishes, the home’s skill mix, the layout of the home, staff competencies, workload and capacity. This is particularly important as staff tell me original pack dispensing takes ‘twice as long’.

Bearing in mind that OPD takes longer, what are the advantages of moving to this? Can you be sure, for example, that unsafe practices such as ‘potting up’ will not creep into use?

My advice about MDS vs OPD is that if you are being lobbied to change to original pack dispensing, is to consider the questions set out below:

I am a nurse by trade and used to be a proponent of OPD in all circumstances. Since working in social care and with residential homes I’ve re-visited this view. I now believe that care home residents need well-designed systems and that, unless the resident can manage their medicines themselves (always the first consideration), a good MDS system is often a much safer way to administer medicines.

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A shorter version of this article first appeared in the Autumn Edition of The Carer.

About the author: Steve is a nurse prescriber, Head of Medicines and Prescribing for www.medicinegov.org , Information Governance Lead for CareMeds Ltd and Associate Lecturer at Plymouth University.

Contact steve@carerightnow.co.uk 07931 919 330. Related blogs & shared learning resources can be found here: www.patientled.education

Date: 14.11.2019

Using technology in care homes – eMAR

October 22, 2019 By Steve Turner

Introduction

Medicines errors in care homes are unacceptably high. A key study found that residents taking 7 or more medicines had a 79% chance of being a victim of a medicines error (Alldred et all 2009).

Best practice in medicines record keeping

The management of medicines in nursing and residential homes is part of a highly complex pathway. It involves multiple staff groups and organisations.

These include the G.P.; all who prescribe medicines and treatments; Care Staff of all grades; Support Workers; Consultants: Specialist Practitioners; and the Pharmacies who supply the medicines.

Benefits of electronic MAR charts

The benefits of implementing electronic MAR charts fall into three categories.

Improved legibility.
Improved access (e.g. if the charts are accessed and updated on a computer or portable device there is less risk of losing, damaging or mislaying them).
eMAR chart systems that obtain the data taken directly from the Community Pharmacy system eliminate the need for transcribing, which is a high-risk area.

In addition to the three benefits mentioned, carefully planned and implemented eMAR systems contribute to a decrease in medicines errors, reduced administrative costs and improved quality of care.

Challenges of implementing electronic MAR charts

There are three ‘bottom line’ challenges to manage when transitioning to electronic MAR charts.

1. Assessing the way the system works is critical, as poorly designed will not deliver benefits, and eventually fail.

The system must be easy to use and jargon-free; using only approved acronyms or mnemonics.

Electronic systems also offer the opportunity to introduce features that enhance safety, some of which, such as time-ordered charts, are difficult to include in a paper-based system.

Here’s a checklist:

2. It is vital that the system handles patient consent; patient confidentiality, system access; ownership of patient identifiable data; storage and transfer of data in a way which is compliant with the laws and regulations of your part of the U.K. This is an important question for you to pose to the supplier, particularly with the advent of General Data Protection Regulation (GDPR), and the new Data Protection Act 2018.

3. It is important to look at current processes and how the new system will work. There been problems where acute prescriptions were needed and supplied by a different pharmacy from the one providing the MAR charts, so the home ended up at times with an electronic MAR and a paper MAR. This causes confusion and increases the risk of errors and/or omissions. Colleagues have told me of instances where this has led to eMAR systems being abandoned.

Training and support requirements

Quality training and support, both during the implementation and on an ongoing basis, underpin all successful healthcare I.T systems and need to be planned from the outset. There are four areas that are sometimes overlooked, that deserve special mention.

1. Many of the users of eMAR systems will be Healthcare Assistants or other non-registered skilled staff. As a result, it will be important that the training they receive reinforces their duty to keep accurate records, and their accountability and role is made clear.

2. A significant number of staff may speak English as a second language. Therefore it is important that eMAR systems do not use any unnecessary jargon, and that any help text is in plain language.

3. Appropriate knowledge of Data Protection (GDPR) and Information Governance Rules and regulations are essential and should be built in to any training programmes.

Overall, consideration needs to be given to the nature and content of the training needed to implement the system, including how this is linked to the policies and procedures and overall governance of the home.

Good suppliers will be able to give advice and support on this.

Conclusion

Record keeping in medicines management is a critical safety area for care homes. The current high level of medicines errors is in care homes affects half a million people in England.

The prospect of implementing electronic systems for recording medicines administration holds great potential but is not itself without risk. It needs to be approached carefully in the light of the complex arrangements and multiple organisations involved in prescribing, supplying, administering and monitoring medicines in care homes.

In time, electronic systems will become the norm for medicines management in care homes.

Given the considerations over choice and implementation of systems, eMAR can overcome problems of legibility, transcribing, and access to records and information in a way that is not possible with paper systems.

In years to come it is likely that, just as most G.P.’s would not want to return to paper systems, care homes will come to see electronic systems in the same way. The main beneficiary from this will be the residents in terms of improved safety.

This, in turn, will benefit care home staff who will no longer be involved in the risky business of sorting out, transcribing and chasing paper records. Care home providers will also benefit through decreased indirect costs associated with more efficient and safer processes.

Reference: Alldred P, Barber N, Buckle P et al (2009) Care home use of medicines study (CHUMS): Medication errors in nursing and residential care homes – prevalence, consequences, causes, and solutions. Report to the Patient Safety Research Portfolio. Department of Health, London.

Steve Turner is Information Governance Lead and Data Protection Officer
for CareMeds Ltd

Author: Steve Turner

Date: 22.10.2019

Changing mindsets and delivering safe care in Cornwall together. #devocornwall

March 20, 2017 By Steve Turner

We want the best health care system in the world, & the most efficient and effective system …

We have an opportunity to do things differently in Cornwall

How do we achieve this?

The challenges in Cornwall

There’s a huge amount going on with health and social care in Cornwall. Including the Sustainability and Transformation Plan [STP]; exposure of abuse and neglect in care homes; concerns over hospital closures, delayed discharges taking up hospital beds, and devolution of services on the way.

Although I have worked in health and care for over 30 years, I struggle to keep up with the issues and understand how services are organised. This isn’t helped by the current polarisation of views.

On the one hand we have a big dose of NHS and Council ‘spin’, excessive bureaucracy and even bullying. On the other hand we have public concern, often expressed around specific issues, and sometimes based on unfounded rumours.

Neither of these positions are helpful, and neither represent the vast majority of people (public, staff and patients) who just want good services delivered by kind people who are open, accountable and transparent.

#devocornwall

We have a great opportunity now with the devolution of health and care services. This will be realised if we all build bridges, and transcend the usual hierarchical boundaries. We all need to listen and learn. Everyone, to coin an overused phrase, needs to step out of their comfort zones.

Why we need to think differently?

Several community hospitals are under threat of closure, leading to anger and dominating the headlines. Less attention is given to identifying and measuring the benefits, and any disadvantages of community hospitals. For example, can they be staffed adequately, bearing in mind this means Doctors, Nurses, Physiotherapists, Radiographers, Dieticians, Speech and Language Therapists, Social Workers etc.? Is home care a viable option for patients and carers? Are there any creative options such as bringing back the old style ‘convalescence’? Is rural isolation and lack of public transport the major issue?

It’s becoming increasingly difficult to book a timely GP consultation. This has led to several inaccurate scare stories in the press about ‘cuts’ to face to face GP contacts. This needs deep thought as there are times when easy access to a GP on the ‘phone, or on-line, may actually be a better option. Access to health information from Community Pharmacies or in NHS run clinics in shopping centres, or better health information and advice available locally, may be more effective approach. Leaving GPs free to spend more time with those who need their help and expertise most.

It’s now widely accepted that the NHS and Social Care is underfunded. Despite this there is still a great deal of duplication and waste in the system. How many times have you been asked to repeat information to Health Professionals which others already have? Do some services overlap, and are there gaps? Do different organisations link seamlessly with other organisations? Are all services accessible to all? Many people have important stories to tell on these areas of inefficiency.

Now’s the time to talk about this, find out what’s planned, and take action together. ‘Patient engagement’ key component of the STP and #devcornwall.

Patients and public need to take the lead on this. It’s not the NHS or Cornwall Council’s plan it’s ours.

Personal views of Steve Turner. MD Care Right Now CIC, a Cornish Company

Version 2

Date: 30/03/2017

This article is adapted from a letter which fist appeared in the St Austell Voice

‘Care means care, Justice in care’ – Guest blog from Mr John Barrass

February 1, 2016 By Steve Turner

Mr John Barrass never imagined he would become a campaigner until his mother became ill. Read his story, featured here in full.

‘CARE MEANS CARE , JUSTICE IN CARE .’

‘THE NURSING HOME SECTOR is in crisis it has been in crisis for the last 20 years.

No rights , No justice , for any of the frail , vulnerable, elderly, it needs a massive political debate of all colours to change it !.

Please have patience to read this DOCUMENT to the end.

Thank you.

John Malcolm Barrass.

29 th October 2015.

THIS DOCUMENT ‘ CARE MEANS CARE ‘ , ‘ JUSTICE IN CARE ‘ .

THIS INVESTIGATION AND THESE RECOMMENDATIONS OF MINE WOULD SEE THE BIGGEST CHANGES AND REFORM SINCE JOHN MAJOR CLOSED LONG TERM WARDS DOWN BACK IN 1989, 26 YEARS AGO !!

WILL YOU READ A HARD STORY TO TELL AN INNOCENT PRISONER , AND THE INVESTIGATION ,WITH RECOMMENDATIONS.
THANK YOU
JOHN MALCOLM BARRASS 4 TH APRIL 2015 .

In this country , if you are old , frail , you are not only vulnerable , you are bottom of the pile , end of your life , so what ,it doesn’t matter.
We have had 20 years or more of appalling care to prove this, had documentaries made , appalling stories told !
Nothing has been done about this.

THE FACTS

Figures from age UK 2012- 13 approx. 50,000 of the vulnerable elderly suffering mistreatment , abuse , neglect ,in nursing homes .

Radio 5 live 22nd Feb 2015, thousands of safeguarding complaints ,elderly , vulnerable ,2013-14, 1 in 5 homes failing key tests .

In the last 5 years 400 small nursing homes closing down, putting the frail elderly vulnerable in larger homes , without enough staff and qualified staff to deal with them , southern cross and many others that charities know about, prove this.

In the next 15 years there are going to be twice the amount of 85 year olds , and 3 times the 65 year olds picking up there pensions.

The system is in CRISIS now .

CQC Chief Inspector Andrea Sutcliffe told BBC Breakfast TV in Oct 2014 ” the standard of care homes in England is not good enough at the moment “.

CQC Chairman David Prior said at the start of the CQC annual accountability at the healthcare select meeting on 16 th Dec 2014 , the CQC are still not fit for purpose “we have not got where we want to be. “

The Parliamentary Healthcare Ombudsman , Dame Julie Mellor has been forced into raising the investigation figures using only the same staff by spending less time than before accessing the cases and more time investigating the cases , still spending less time than before, pushing the investigating figures up from 400 to 2000 .

When you are spending less time doing both what happens to the serious cases as before as my mother’s , and cases like the Titcombe babies case , and the Sam Morrish boy’s case down here in Devon.

But what purpose are the Ombudsman there for they are not there to investigate nursing homes , they are there to investigate government depts. and the NHS hospitals.

The total cost to the taxpayer together is in excess of £400 million .

What are they getting for there money , an antiquated system , falling apart at the seams.

There are many many other revelations I could go on and on about .

That is why charities like the patients association , and many more are inundated with complaints that the Ombudsman are not looking into there cases properly .

Mr Barrass asks “when will this appalling treatment under the name CARE for the vulnerable ,elderly,frail ,in nursing homes in this country end ” .

The answer he believes after investigating the system for 5 years is in this document below. On the 26th May 2005 my mother suffered in the medical terms a dense right sided hemiparesis total anterior circulation, stroke left her aphasic , with a dense right hemiplegia.

A serious stroke needing 24 nursing care , having multiple health problems and multiple health needs.

This is what care she received and how she had to die.

AN INNOCENT PRISONER.
THIS IS A HARD STORY TO TELL.
Imagine what it must be like to be paralysed on one side ,unable to talk or call out for help ,press a buzzer, eat or drink, unable to walk , then imagine being fed and watered via a tube, the only quality of life you have is to see and hear people.
You are told you need a stimulating environment and responsive therapy.
Instead you are placed in a nursing home which is unsuitable for your needs.

Denied a correct chair for your quality of life, you cannot get out of your room for 4 months, then given a standard transit wheelchair deemed to be unsafe, under the health and safety factor ( had to support mums head once for 2 hrs with my own hand whilst wheeling her around in this chair ) , had to use this chair for 8 months, then when given the correct chair, but not enough staff to get out you out of your room on a regular basis.

Imagine being left in a soiled bed for 1 to 3 hrs,(one time left for 1 hr 20 mins the staff preferred to have there tea break first) However your mouth is not swabbed regularly so you develop crusty lumps around your teeth and on your tongue , nearly die in the first month of care , due to a chest infection not dealt with properly and promptly, blood tests not done on time, and then develop the worst case of constipation a hospital Dr has seen in 9 years, because you were not given the correct bowel medication, care home Dr say your family are fixated on this.

ALL THIS HAPPENED IN A NORTH DEVON NURSING HOME ,DEEMED TO BE ONE OF THE BEST IN DEVON.
WHAT MUST ALL THE OTHERS BE LIKE?
ARE YOU SHOCKED AND APPALLED.

On 23 rd October during the early hours of the morning , my mum died in a North Devon Hospital.
The last 6 days of her life saw her experience great suffering beyond anything she had already endured in the 4 years leading up to this time and place

THESE ARE MY MUMS FINAL 6 DAYS.
Her feed tube needed changing ,could and should have been changed one month earlier. Due to this, complications set in .
( which involved a drug , flu vaccination, super public catheter ) .
Mum’s last 6 days not checked by a Doctor , no management on at the weekend, allowed to have a feed tube change on Monday, when clearly condition at weekend needed looking into.
After being administered a Flu Jab one afternoon by the evening she had mucus / saliva running from the corner of her mouth like a water tap switched on, this continued for 4 days, then subsided for 6 days.

Day one Saturday. However when swabbing mums mouth I noticed a massive / piece and amount of mucus / saliva heavy phlegm . Staff told us it was only phlegm and did not call a Doctor.

Day two Sunday. Mum has vomited brown liquid, staff said it looks like dried blood, they did not call a Doctor , nor the home management.

Day three Monday. Mum went into hospital to have her feed tube changed (endoscopy) . When she arrived back at the home, her tongue and lip were swollen followed later by difficulties with congestion (upper throat and chest) , still no Doctor called. A temperamental red suction machine has been left in mums room.

Day four Tuesday. Mum still has congestive problems with a swollen tongue and lip with bruising under her chin again no Doctor called. Arranged to see the nursing home Doctor tomorrow, on his regular Wednesday visit.

Day five Wednesday. I discovered mum had a tooth missing , which no one recorded or explained to us how where and when it happened , yet two nurses told us they noticed it missing? , I noticed a hospital suction machine left in mum’s room (serious issues arise from this discovery ) the nursing home Doctor who we asked to see the day before had disappeared before we got there? , told by staff he had ordered antibiotics for mum.
After this the emergency Doctor was called who immediately rang for an ambulance and oxygen for mum.
Mum arrived at the hospital 4 blood tests were taken.
One arrived within 30 mins , found she had a major infection, put her on antibiotics , she was transferred to the medical assessment unit, her breathing has eased a little.

Day six Thursday. I arrive to see mum it feels if she has been given up on, I am told she is very poorly. She has been taken off the antibiotics and saline drip . Her breathing and congestion has got worse. Why has she been left to die like this just 3 days after all she went through?
It is a shock and more than I can bear.

QUESTIONS ARE RISING FROM ALL OF MUM’S CARE AND LAST 6 DAYS!

1. The parliamentary ombudsman would not investigate this only access!
2.We have 20 questions and issues unanswered by the p ombudsman!
3.Find they had 9 limited powers to investigate!
4.The legality side, costs outweigh compensation for the elderly.
5.After 5 years investigating this , nowhere to go to get this looked into properly or fairly!
6.This raises serious questions for everyone!
7.If they cant look into mum’s case properly or fairly !
8.They cant look into anyone else’s properly or fairly!
9.How can this be right!

WHAT WE WANT ANSWERS TO ARE :-
Why did my mother go to have a feed tube change to keep her alive , to die 3days after!
Why was my mother put through all of this !
For what reason!
I simply ask the question WHY.

QUESTIONS I ASK DURING MY MOTHERS TREATMENT,AND MY 5 YEAR INVESTIGATING THE SYSTEM IN GREAT DETAIL ARE :-
1.Are the parliamentary Ombudsman fit for purpose to look into private nursing homes?
2.Are the CQC fit for purpose when they still do not look into individual cases in nursing homes?
3.Have nursing homes got enough staff and quality staff to take care of vulnerable patients who need 24 hour care?
4.Should patients like my mother ever have been put into these homes ?
5.Should there be special NHS units for 24 hour care patients with multiple health needs like my mums ?
6.What rights have the old , frail, and vulnerable got in private nursing homes?
7.Continuing health care funding for the very vulnerable paid by the tax payer to private nursing homes, yet have loopholes in the system not to be investigated thoroughly ?
8.Care means Care whether it is Private or NHS, when anything serious happens in nursing homes, and it involves the hospital NHS, both sides will not comment what the other side have done , yet are both caring for a patient, so the patient gets caught in the middle of all of this not getting clear answers to what has happened to them?
9.Equipment ie specialist equipment , profiling beds etc, no law to make the nursing homes provide , the CCG were set up to deal with this, but still problems with no law to provide?
10.Because of the system as it is ,when anyone finds anything out no one will talk after fear of legal action, there has to be a new system free from legal interference?
11.Because of continuing health care paid for 24 hr vulnerable patients, paid by the taxpayer, it is the Government NHS responsibility not the legal responsibility to investigate accountability and answers for the families of love ones who have been affected ?

MY RECOMMENDATIONS!

1.A big political debate about all my investigation raises!
2. The PASC should hold meetings only about the nursing home sector and nothing else ,so they know more and can scrutinise more!
3.The CQC and the parliamentary Ombudsman are not fit for purpose anymore to inspect , regulate , and investigate nursing homes and a new one body only needs to be set up , with more powers to regulate , inspect ,investigate nursing homes doing the job together, to investigate all individual cases , to get accountability , free from legal interference .
4.Because the system as it stands at the moment , no one will ever get justice.

No one under the word ‘Care’ should ever have to go through this .

Don’t let this happen to anyone’s mother again.

When independent consultant nurse Lynne Phair said in the Panorama Documentary ‘Behind closed doors ‘ on 30th April 2014 ” To pull out a vulnerable patients buzzer is to cut there lifeline , and to imprison them “.
That must be what happened to my mum , she was imprisoned for a crime she did not commit.
I believe these deplorable events must be brought to the public’s attention to prevent similar things happening again, after all , anyone of us who cannot talk , shout out for help without enough staff and quality staff to look after us must be in prison too.

Thanking you all for taking the time to read this,It is desperately important this gets out to the public.
Anything you can do to help will be appreciated .
Yours Sincerely
John Malcolm Barrass.
Thursday 26 th March 2015. ‘

Click here for a one page commentary by Steve Turner

Turn Up The Volume! Listening for safer care – graffiti walls

November 3, 2015 By Steve Turner

On 16th October we held a unique learning event, bringing together whistelblowers and health leaders from all quarters (staff, public, patients, carers, relatives) to speak out for safer care.

We collected (and continue to collect) a large amount or information, in the speaker videos , graffiti walls, question and answer sessions, feedback forms, emails, twitter (under #turnupbristol).