New advice from NICE (2017) means all medicines support should be recorded on a medicines chart

01 Sep New advice from NICE (2017) means all medicines support should be recorded on a medicines chart

Summary: Following new advice from NICE (March 2017) for community settings [1], all medicines support provided to a person should be recorded on a medicines chart. NICE may apply this to care homes with the next revision of their medicines guidelines.

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In detail

There is an age old question that has rumbled on for years with medicines in social care settings, namely: are staff prompting, assisting, or administering medicines to people using the service This important question has implications for how staff are trained, how medicines are recorded, and what forms and processes are needed in your medication policy. Advice changed this year with the issue of new guidelines from NICE in March 2017: “Managing medicines for adults receiving social care in the community” [1]. If you work in a care home, NICE may take the same line when they review your medicines management guidelines for care homes.

What did the previous standards say?

Previously, three documents addressed this issue: “The administration of medicines in domiciliary care” (CQC, 2007) [2]; “Training care workers to safely administer medicines in care homes” (CQC, 2007) [3]; and “The Handling of Medicines in Social Care” (Royal Pharmaceutical Society, 2007) [4]. In these documents, three levels of support with medicines were set out.

Level 1: General Support (also called Assisting with Medicine)

Here, the person using the service is self-medicating, with physical assistance from a support worker. The care worker must work under the direction of the person using the service, who must indicate to the care worker what actions they are to take on each occasion. If the person using the service doesn’t provide this direction, or if the care worker gives any medicines without being requested (by the person), this activity is interpreted as administering medicine [2]. The CQC list some examples [2] [3]:

• requesting prescriptions, collecting medicines, disposing of medicines
• occasional reminders (prompts), but not regular prompts
• manipulation of containers e.g. opening a bottles or popping tablets from blister packs when the person requests this and shows them which medicines to select

CQC stated that for level 1 General Support, staff members should receive induction training to “raise awareness of the management of medicines within the home, and identify what the care worker is not able to do before completing level 2 training. For example, how care workers should respond when someone asks for paracetamol for a headache.” [2]. In terms of where to record general support tasks, no clear answer was ever given either by CQC or by the Royal Pharmaceutical Society [2] [3] [4].

Level 2: Administering Medication

Here, the care worker is taking responsibility for ensuring that medicines are taken correctly and on time. CQC give some examples [2] [3]:

• selecting/preparing medicines for immediate administration, including selection from a monitored dosage system or compliance aid
• selecting/measuring liquid medication
• application of medicated creams/ointments; ear, nose or eye drops; inhalers
• putting out medication for the person to take later (to enable their independence)

The training requirements that support staff need to administer medicines should cover those elements of the Skills for Care Knowledge Set for Medication that apply to their care setting [1] [2] [4]. Nowadays the Skills for Care Knowledge Set has changed into HSC Unit 3047 “Support the Use of Medication in Social Care Settings”. It’s basically the same knowledge set, but just re-titled and it’s the training that we provide at Prescription Training.

In terms of where to record the administration of medicines, none of the documents were really clear on this, but most care providers were happy to use a “medicines chart”. As no advice was printed from CQC or the Royal Pharmaceutical Society on what information a medicines chart should contain, lots of different formats are out there, some quite limited (for example, just having a tick against “blister pack” on a certain date). When you speak with the CQC pharmacists, they will tell you that these types of record are not robust enough, but without clear guidance on what a medicines chart should look like, it’s hard for CQC to inspect against.

Level 3: Administering medication by specialised techniques.

For the sake of completeness, we should mention level 3: Administering medication by specialised techniques [2][3][4]:

• Rectal administration, e.g. suppositories, diazepam (for epileptic seizure)
• Insulin by injection
• Administration through a Percutaneous Endoscopic Gastrostomy (PEG)
• Giving oxygen

Training and competence checks must be provided by a healthcare professional [2][3][4]. Although this list was helpful, what about buccal midazolam, nebulisers, etc.? Are these administration by specialist technique?

So you can see that whilst guidance was out there, it still left many questions unanswered.

So what’s the new advice from NICE that CQC will follow?

In 2012, NICE took over from CQC and the Royal Pharmaceutical Society in developing the main medication guidance for social care. In March 2017, NICE issued “Managing medicines for adults receiving social care in the community” [1]. This document states:

1.5.2 Care workers must record the medicines support given to a person for each individual medicine on every occasion, in line with Regulation 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This includes details of all support for prescribed and over-the-counter medicines, such as:

• reminding a person to take their medicine
• giving the person their medicine
• recording whether the person has taken or declined their medicine (see also recommendation 1.6.4 on raising concerns).

1.5.3 Care workers should use a medicines administration record to record any medicines support that they give to a person. This should ideally be a printed record provided by the supplying pharmacist, dispensing doctor or social care provider (if they have the resources to produce them) (see also recommendation 1.9.10 on supplying medicines administration records). NICE define “medicines support” as “Any support that enables a person to manage their medicines”.

In 1.5.5 NICE state that medicines administration records include:

• the person’s name, date of birth
• any other available person-specific identifiers, such as the person’s NHS number
• the name, formulation and strength of the medicine(s)
• how often or the time the medicine should be taken
• how the medicine is taken or used (route of administration)
• the name of the person’s GP practice
• any stop or review date
• any additional information, such as specific instructions for giving a medicine and any
• known drug allergies.

So does this mean that general support tasks (assisting) now need to be recorded on a medicines chart?

It would seem that the answer is yes. Some people have argued that NICE have used the word “should” rather than “must” in 1.5.2. However, in my experience the NICE guidance will be seen as robust when it comes to care standards tribunals in magistrate courts, so whilst the guidance may state “should”, the courts would rely on this as practice to be considered and adhered to by the service when considering a case. It’s worth stating that some CCGs and councils we have spoken to still disagree with this, so you might want to check their policies.

What will CQC do?

Having spoken with a few contacts at CQC, I think that they will take a more accommodating line with care providers and judge each case on an individual “person using the service” basis. There are a large number of domiciliary care providers out there who don’t use MAR charts of a robust standard and it will take a while to get people to change.

In conclusion

Whilst CQC may take a more accommodating line, I think NICE guidance is pretty tight here, and it’s the judge at a care standards tribunal you need to think about. They’ll go straight to the NICE guidance.

My view is that you should record all administration of medicines and all general support tasks (including prompting) on a robust medicines chart that complies with point 1.5.5. You’ll also need when required protocols and a medicines reconciliation form for recording the up to date list of medicines a person uses with information such as start/stop/review dates (i.e. any of the information in 1.5.5 that isn’t recorded on the medicines chart). We have these medicines charts and forms on our website.

At the end of the day, how many people that your staff are providing general support tasks to, are truly checking that staff are giving them the correct medicines at the correct times in the correct way on every occasion? In my experience, even if clients does check to start with, they soon start to trust the support worker and responsibility soon shifts onto that support worker (which means that the support worker is administering medicines).

When this happens, you want to ensure staff members have the training, medicines charts, forms and a medicines policy that keep them, you, and the people they support, safe.

If you want more information or want to discuss how this might affect you, call us (01273 917210), email us or click here to find out about our open workshops running this month.

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References

1. Managing medicines for adults receiving social care in the community. NICE guideline, published 30 March 2017.
2. Professional advice. The administration of medicines in domiciliary care. Care Quality Commission 2007.
3. Professional advice. Training care workers to safely administer medicines in care homes. Care Quality Commission 2007.
4. The Handling of Medicines in Social Care Settings. Royal Pharmaceutical Society, 2007.