Safe handling and administration of medicines in care homes – implementing NICE Guidance – supporting person centred care
Scope of the guideline
The NICE Guidance on Managing medicines in care homes, issued in March 2014, has wide ranging implications for service providers. This is the first combined health and social care guidance produced by the National Institute for Health and Care Excellence [NICE]. The guideline applies to all registered providers of any size of care home for people of all ages, including those who need nursing care. This includes accommodation for children and for those with a learning disability. It represents a big step forward, as there were no previous comprehensive guidelines in this area. It was produced is in response to concerns over medicines safety as highlighted in the CHUMS report; the need to implement robust systems used for managing and administering medicines, and the need to ensure consistent standards are met.
In addition to medicines handling, administration and documentation the guideline covers the processes for reviewing medicines, prescribing and ordering medicines, dispensing and supplying medicines, receiving, storing and disposing of medicines, administration of medicines by care home staff, the covert administration of medicines, and the administration of medicines for minor ailments that can be bought without prescription, such as paracetamol for headaches or remedies for indigestion.
The principles underpinning this Guideline are that people in care homes have the same rights as those in other settings, as set out in the NHS Constitution for England. The guideline supports the principle that all residents should have the opportunity to make informed decisions about their care, and stresses the need to enable residents to live as independently as possible. The National Care Forum document Safety of medicines in the care home (2013) identified that ‘when a person enters a home, staff often automatically assume responsibility for managing medicines. This can lead to a loss of independence and control for the resident’. The recommendations include the need for each resident have medicines risk assessments, in order to determine how much support they need.
The recommendations link to initiatives around reduction of harm from medicines errors. These include robust medicines incident reporting; sharing this information; root cause analysis; implementing and sharing the resulting learning, and informing relatives of how to report medicines incidents. Drug errors can occur both in the care home and on transfer, particularly for the increasing number of residents with multiple long-term conditions who move between care settings, who may have more than one prescriber, and be taking multiple medicines (polypharmacy). Although most medication errors have negligible consequences for residents, in some cases they may have serious, potentially life-threatening consequences.
Recent reports show that:
- Two thirds of care home residents were shown to be exposed to a medicines error
- Over 90% of the 345 residents included in one study were exposed to at least 1 potential medication administration error over a 3-month period.
- The link between poor record keeping and this unacceptable level of medicines errors is supported in reviews of the causes of medicines incidents
- Poor communication of information at transition points is responsible for as many as 50% of all medication errors
Delivering ‘medicines optimisation’
The term ‘medicines optimisation’ is more comprehensive than medicines management. It is used to describe the whole process around medicines, including patient choice and adherence.
This guideline supports implementation of medicines optimisation. It includes the recommendation that residents have access to any support they need to enable them to take part in decision-making. This involves considering any mental health problems, any sight or hearing problems, any difficulties reading or speaking English, or any cultural differences that a person may have that might mean extra help is needed. These should be recorded in the person’s care plan and should be checked regularly.
A summary of key recommendations
- Care Homes to have a written medicines policy and procedures, including procedures for ordering, supplying, dispensing receiving, storing, administering, monitoring and disposing of medicines
- A dynamic and robust process for covert administration of medicines
- Residents to be supported to make informed decisions
- Assume the resident can look after their medicine themselves in the first instance
o If this is the case carry out a risk assessment and devise a safe system for the resident
o Where needed allow residents to store their own medicines safely
- A clear process to assist in sharing information, including when residents move care settings
- An accurate and up to date list of the residents medicines available (medicine’s reconciliation)
- Records to be full, accurate and up to date
- A robust process for reporting and reviewing medicines-related problems
o Including all suspected adverse effects of medicines to be reported
- Robust safeguarding procedures in place, including reporting arrangements to be included in commissioning contracts
- Robust medicines incident reporting, root cause analysis and sharing learning
o Including residents and family members to know how to report
- Comprehensive written procedures for prescribing, including as required (prn) medicines, variable doses and anticipatory medicines
- Care home providers retain responsibility for ordering medicines, allowing protected time for this
- Medicines administration records to be produced by supplying pharmacies wherever possible
- Appropriate training and skills for care staff who handle and administer medicines
o Designated staff to administer medicines only after completing training and assessed as competent
- Reliable and up to date information about medicines used easily available to staff, residents and relatives
|Implications for care home managers and ownersImplementing the NICE recommendations represents a challenge for providers, who will need to consider technology such as eMAR systems; individual storage of residents’ medicines, and patient held medicines records, in order to facilitate new ways of working.Ultimately this will help deliver a person centred service fit for the 21st century, and be part of a revolution in care for residents with complex needs.
Author: Steve Turner, Managing Director, Care Right Now (CIC)
Steve is NICE Medicines and Prescribing Associate and a CQC Specialist Advisor