1. Purpose
This policy sets out how the Service manages medicines safely, including administration, storage, transport, disposal, records, refusals, covert administration, PRN medicines, errors and learning.
The Service must verify this policy against NICE social-care medicines guidance, CQC medicines guidance, medicines legislation, controlled-drug requirements and local pharmacy procedures before adoption.
2. Sources to verify before adoption
- NICE SC1, Managing medicines in care homes: https://www.nice.org.uk/guidance/sc1
- NICE SC1 recommendations: https://www.nice.org.uk/guidance/sc1/chapter/1-Recommendations
- CQC adult social care medicines management: https://www.cqc.org.uk/guidance-providers/adult-social-care/medicines-management
- CQC medicines care plans: https://www.cqc.org.uk/guidance-providers/adult-social-care/medicines-care-plans
- CQC training and competence in medicines optimisation: https://www.cqc.org.uk/guidance-providers/adult-social-care/training-competence-medicines-optimisation-adult-social-care
- Mental Capacity Act 2005: https://www.legislation.gov.uk/ukpga/2005/9/contents
- Misuse of Drugs Regulations 2001: https://www.legislation.gov.uk/uksi/2001/3998/contents
- Controlled Drugs (Supervision of Management and Use) Regulations 2013: https://www.legislation.gov.uk/uksi/2013/373/contents
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20: https://www.legislation.gov.uk/uksi/2014/2936/regulation/20
3. Scope
This policy applies to:
- medicines administration
- medicines support and prompting
- ordering and receipt
- storage and security
- transport between settings
- disposal and returns
- MAR chart records
- controlled drugs
- PRN medicines
- refused medicines
- covert administration
- medication errors and near misses
It applies to prescribed medicines, non-prescription medicines, homely remedies where used, topical preparations, nutritional supplements and controlled drugs.
4. MAR chart standards
The Service keeps a current medicine administration record for each person receiving medicines support.
MAR records include:
- person's name and date of birth
- medicine name, strength, form and route
- dose and timing
- start date and stop date where relevant
- allergies and sensitivities
- prescriber or pharmacy source where relevant
- administration record
- reason for omission or refusal
- staff initials and signature list
- PRN protocol reference where relevant
- topical body-map reference where relevant
Staff do not transcribe medicines unless they are trained and authorised under the Service procedure. Any handwritten or amended entry is checked according to current NICE SC1 guidance and local pharmacy process.
5. Administration, storage, transport and disposal
Medicines are administered only by staff who are trained, competent and authorised for that task.
The Service:
- stores medicines securely and according to the medicine instructions
- records fridge temperatures where medicines require cold storage
- keeps medicines separate for each person where required
- transports medicines securely when people move between settings
- records medicines received and returned
- disposes of medicines through the approved pharmacy or waste route
- keeps records of disposal and returns
The Service verifies storage, transport and disposal detail against NICE SC1, CQC medicines guidance and pharmacy advice before adoption.
6. Controlled-drug register
Where the Service holds controlled drugs requiring register controls, the Service keeps a controlled-drug register.
The register records:
- date and time
- person using the service
- medicine name, strength and form
- quantity received, administered, returned or disposed of
- running balance
- signature of staff member administering or checking
- witness signature where the current procedure requires two-person witnessing
- reason for discrepancy and action taken
The Registered Manager sets the reconciliation cadence from current controlled-drug legislation, NICE SC1, pharmacy advice and local procedure. This template does not restate controlled-drug legal intervals.
Any discrepancy is escalated immediately to the senior person on duty and Registered Manager.
7. Refusal of medication
A person can refuse medicine if they have capacity for that decision.
When a person refuses medicine, staff:
- offer information and support in a way the person can understand
- do not force or hide the medicine
- record the refusal on the MAR chart
- record the reason where the person gives one
- follow the PRN or prescribed medicine protocol where relevant
- inform senior staff where refusal creates risk
- seek prescriber or pharmacist advice where repeated refusal or high-risk medicine is involved
- review capacity where there is reason to doubt capacity for the decision
Refusal patterns are reviewed through care-plan review and medicines audit.
8. Covert administration MCA pathway
Covert administration is used only where the person lacks capacity for the specific medicine decision and the process is lawful, necessary and in the person's best interests.
Before covert administration starts, the Service records:
- capacity assessment for the medicine decision
- best-interest decision
- consultation with the prescriber, pharmacist and people interested in the person's welfare
- why alternatives are not suitable
- medicine-specific administration advice
- review date
- care-plan wording
- MAR chart instruction
Covert administration is never used for staff convenience. The Service verifies the process against the Mental Capacity Act 2005, NICE SC1 and CQC medicines guidance before adoption.
9. PRN protocols
Each PRN medicine has a person-specific protocol.
The protocol records:
- what the medicine is for
- signs or symptoms that indicate use
- dose and maximum dose according to the prescription
- minimum interval according to the prescription
- non-medicine approaches to try where appropriate
- when to seek senior or clinical advice
- how effect is reviewed and recorded
- when the protocol is reviewed
Staff record the reason for giving PRN medicine and the outcome.
10. Medication review with prescribers
The Service supports regular medication review with prescribers, pharmacists and relevant healthcare professionals.
Review is considered:
- after admission or start of support
- after hospital discharge
- after medicine change
- after falls, sedation, swallowing concern or weight change
- after repeated refusal
- after medication error
- when the person, family, staff or prescriber raises concern
- at planned care review
The Service does not set clinical review intervals from this template. Staff check NICE SC1, prescriber advice and local medicines pathway.
11. Medication errors and learning
Medication errors and near misses are recorded as incidents.
Staff:
- make the person safe
- seek clinical advice where needed
- inform senior staff and the Registered Manager
- record what happened
- preserve MAR chart and medicine evidence
- inform family or representative according to consent and duty of candour requirements
- consider safeguarding, CQC notification and Regulation 20 duty of candour
- assign corrective actions
The Registered Manager reviews medication incident themes at least monthly.
12. Staff competency assessment
Staff administer medicines only after training and competency assessment.
Competency covers:
- medicines policy and procedure
- MAR chart use
- infection prevention during administration
- medicines storage
- controlled-drug process where relevant
- PRN protocols
- refusal
- covert administration escalation
- error reporting
- person-centred communication
Competency is reassessed after concern, incident, long absence or procedure change.
13. Audit cadence
The Registered Manager audits medicines practice at least monthly.
The audit includes:
- MAR chart completeness
- omissions and refusals
- PRN records
- controlled-drug balances where relevant
- storage and temperature records
- disposal and returns
- medicine errors and near misses
- covert administration records
- staff competency records
- medication-review actions
Audit findings are recorded as improvement actions with an owner and review date.
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.