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Medication

Introduction

Utilise the HCPA Medication page for Care Homes and Community Services in Hertfordshire. These resources and guidance have been sourced in conjunction with local specialists and national guidance.

Medicines guidance for HVCCG and EN Herts Care Homes

» Herts Valley Website
» EN Herts website

Contact information:

 

National Guidance – Care Home

Title Info Link
National Institute for Health and Care Excellence (NICE) guideline: Managing medicines in care homes NICE published this guideline in March 2014; it considers all aspects of managing medicines in care homes and recommends that all care home providers have a medicines policy that includes written processes. The policy should ensure that processes are in place for safe and effective use of medicines in the care home. NICE Guideline SC1: Managing medicines in care homes
NICE Guideline SC1: Tools and Resources
National Institute for Health and Care Excellence (NICE): Checklist for care home medicines policy NICE have produced a checklist for health and social care staff on developing and updating care home medicines policies. It gives more information about the processes that should be covered. Click here
Care Quality Commission (CQC) learning from safety incidents: Issue 5: Safe management of medicines When something goes wrong in health and social care, the people affected and staff often say, “I don’t want this to happen to anyone else.” These ‘Learning from safety incidents’ resources are designed to do just that. Click here 
CQC Medicines: information for adult and social services Information provided by the CQC on different medication regarding high-risk medications, storage, oxygen, administering and much more. Click here
Medicines PIL All recent updates of medication in one place. Click here
National care forum meds safety resources Free resources for supporting the safe use of medications in care facilities. Click here
Care Homes use of Medicines (CHUMS) Study: Medication errors in nursing & residential care homes ‐ prevalence, consequences, causes and solutions. Report to the Patient Safety Research Portfolio, Dept of Health. Click here
CQC document – Medicines in Health and Adult Social Care We know that people’s physical and mental health outcomes improve when medicines are used in the best or optimal way. When they are not prescribed or administered correctly they can cause harm. Click here

 

National Guidance – Community Services

Title Info Link
National Institute for Health and Care Excellence (NICE) guideline: Managing medicines for adults receiving social care in the community This guideline covers medicines support for adults (aged 18 and over) who are receiving social care in the community. It aims to ensure that people who receive social care are supported to take and look after their medicines effectively and safely at home. It gives advice on assessing if people need help with managing their medicines, who should provide medicines support and how health and social care staff should work together. NICE Guideline NG67: Managing medicines for adults receiving social care in the community

NICE Guideline SC1: Quality StandardNICE Guideline SC1: Tools and Resources
Care Quality Commission (CQC) learning from safety incidents: Issue 5: Safe management of medicines The ‘Learning from safety incidents’ resources have been developed to share common critical issues identified from CQC’s criminal prosecution work against providers that have failed to provide care and treatment in a safe way. The ‘safe management of medicines’ resource includes prescribing, handling and administering medicines. Click here
CQC Medicines: information for adult and social services Information provided by the CQC on different medication regarding high-risk medications, storage, oxygen, administering and much more. Medicines Information Adult Social Care Services
Administering medicines in home care agencies
Medicines PIL All recent updates of medication in one place. Click here
National Care Forum meds safety resources Free resources for supporting the safe use of medications in care facilities. Click here

 

HCC Medication Domiciliary Care Policy

This document outlines the roles, responsibilities and procedures for assisting people living in their own homes in receipt of regulated and non regulated homecare and community support with prescribed medications as part of their care and support plan. It sets out the procedure from handling and administering medicines, and for their safe storage and disposal. It also outlines what documents should be used and how records should be kept.

» View the full policy here

See the source image

 

Education and Competencies

Please visit HCPA’s training page to see what medication training HCPA and the County Council are delivering, you will also find information on how you can claim mandatory funding for medication training at your service.

Click here to view HCPA’s Training Page

Although, HCPA does not endorse e-learning as quality training (click here for the Hertfordshire Blended E-Learning Policy). We have been advised of the below medication e-learning from PrescQIPP which you could use to enhance face-to-face training.

PrescQIPP

The Hertfordshire clinical Commissioning groups have funded the use of PrescQIPP E-learning package for Care Home staff across the County. As you will be aware E-Leaning is not considered good enough by itself and should be accompanied with Face to face training and monitoring of competencies to form a Blended Learning Package.

Medication E-Learning available for free via PresQUIPP

» PresQUIPP – Medicines use in care homes: E-Learning course 1-3
» PrescQIPP – Managing medicines for adults receiving social care in the community: E-Learning course
» Guide to log in to PresQuipp if you are a Care Home
» Visit e-learning website here

Medicines Use in Care Homes Course e-learning Medicines Use in Care Homes: Course 2 e-learning pdf
The Care Homes 1 e-learning package is aimed at all care home staff involved with managing medicines. It is the first of several-planned e-learning packages for Care homes and will include the following modules in addition to three case studies to help apply learning to practice. The Care Homes -2 e-learning package builds on the content covered in the Medicines use in care homes: Course 1 and includes 7 modules focusing on key topics, in addition to three case studies that will help apply learning to practice
> Module 1 – Welcome and introduction > Module 1 – Welcome and introduction
> Module 2 – The role of CQC and the NICE guideline and quality standards > Module 2 – Refused and omitted doses
> Module 3 – The management of medicines in care homes > Module 3 – Covert administration
> Module 4 – Management of self-medicating residents > Module 4 – Managing controlled drugs
> Module 5 – Administration of inhalers > Module 5 – Bulk prescribing
> Module 6 – The management of medicines in care homes > Module 6 – Homely remedies
> Module 7 – Administration of transdermal patches > Module 7 – Medicines waste reduction.
> Module 8 – Administration of topical products
> Module 9 Administration of PRN medicines

Further information about the course and how to access the course is included in the flyer here. 

Further information about the course and how to access the course is included in the flyer here.

Prescribing and Compliance Aids- All settings

Guidance for Optimising Medicines Support for Patients – Seven Day Prescribing & Multi-compartment Compliance Aids (MCA) Best Practice.

MCAs are also known as blister packs or dossette boxes.


(image credit – Helping Hands)

» Click here to access guidance

Key points and Changes

  • The community pharmacist is under no obligation under the Equality Act to supply patients with an MCA (dossette box) who have paid carers that administer the medicines, including in Care Homes
  • Community pharmacy will only provide MCAs (dossette boxes) free of charge to those who are assessed under the Equality Act criteria. Where there is no NHS funding other patients may be given an alternative aid to assist their compliance or be charged a fee.
  • 7-day prescriptions are only needed if a decision has been made by the prescriber e.g. GP on clinical and patient safety grounds that medication should be issued to the patient on a weekly basis. Prescribers will determine the prescription duration.
  • It is the dispensing pharmacist’s responsibility to determine how to apply “reasonable adjustment” to patients, to help support safe self- administration. Examples may include; use of large, bold font on labels; use of winged bottle caps or supply an appropriate compliance aid e.g. dossette boxes and eye drop dispensers.
  • The community pharmacy can provide further information on the range of compliance aids and devices available.
  • HCC will be notified if care agencies/staff request dossette boxes for staff to administer from as this is not supported in the HCC medicines policy

Have you more questions? – read the FAQs, refer to the Hertfordshire County Council Medication Policy or contact your CCG PMOT team via email address: enhertsccg.pmot@nhs.net or hvccg.pmot1@nhs.net

Oral Nutritional Supplements- All Settings

Local guidance

Subject Description Links
Adult sip feeds (ONS) in primary care A quick reference for health and care professionals (including care home staff) regarding identification and treatment of malnutrition in the community. It contains links to all other ‘food first’ documents on the CCG website, in addition to essential guidance on when it is (and is not) appropriate to prescribe ONS and the most cost effective ONS to prescribe.

  • Malnutrition should be identified using the Malnutrition Universal Screening Tool (MUST) before treatment is commenced (medium or high risk = malnourished)
  • Treatment of malnutrition should start with a ‘food first’ approach using the resources below
View the Managing Malnutrition Pathway

 

Food First – Eating well for small appetites A self-explanatory leaflet designed for patients at medium or high risk of malnutrition according to MUST. It focuses on enabling patients to increase their nutritional intake by at least 500 calories per day and can be given out by any healthcare professional without additional explanation View Guidance
Food First – Quick guide A short version of the above leaflet. It demonstrates how an additional 500 calories can be consumed simply by making 3 or 4 small dietary changes each day View guidance
Food First – Homemade supplements Designed for patients at high risk of malnutrition according to MUST and should be provided together with ‘Food first – Eating well for small appetites’. It is equally suitable to be used for patients living in their own homes or in care homes View guidance
Eating and drinking at end of life A self-explanatory leaflet designed for the relatives and carers of people who are reaching the end of their lives. It has been requested by a number of GPs and Dietitians, in order to help reassure carers that loss of appetite and reduction in food intake is a normal and expected part of the dying process and that prescribed nutritional products are unlikely to be appropriate at this stage. View guidance

Food First

Fortifying food is a brief practical guide for Care Home cooks/chefs on how to fortify food for residents at medium or high risk of malnutrition according to MUST. It guides cooks/chefs to use fortifiers which contain more than just fat, and to use an adequate amount of each fortifier so that this counts towards intake of an additional 500 calories per day. For more details about fortifying food click here

 

Ways to adapt the recipe Energy Kcal (calories)
Food 1 Portion Adapt by: Before After
Milk 1 pint Add 4 heaped tablespoons dried skimmed milk powder (DSM) to 1 pint whole milk 375 774
(106% extra)
Custard Large ladle (125mls) Add 1 heaped tablespoon DSM powder & 2 tablespoons double cream to custard made with whole milk 140 340
(143% extra)
Soup Large ladle (125mls) Add 1 heaped tablespoon DSM powder & 2 tablespoons double cream 80 280
(250% extra)
Porridge Large ladle (125mls) Add 1 heaped tablespoon DSM powder & 2 tablespoons of double cream to porridge made with whole milk 170 370
(118% extra)
Mashed Potato 1 scoop Add an extra heaped teaspoon of margarine / butter and tablespoon of cream to mashed potatoes 70 190 (170% extra)
Vegetables 2 Tablespoons Add 1 heaped teaspoon of margarine / butter to vegetables. Allow to melt. 15 85
(460% extra)
Ice Cream 1 Small Scoop Pour 2 tablespoons of double cream over ice cream 100 200
(100% extra)
Sponge Pudding 2 Tablespoons Place an extra 2 teaspoons of jam or syrup on the sponge when serving. Serve with a high calorie custard or ice cream 340 540
(58% extra)
Breakfast
Cereal
Small serving (25g) Use fortified milk with 2 tablespoons of double cream and 2 teaspoons of sugar 200 430
(115% extra)
Milk Pudding Large ladle (125mls) Add 1 heaped teaspoon DSM powder & 2 tablespoons double cream to the milk pudding made with whole milk. Serve with 2 teaspoons jam 200 500
(150% extra)

Reducing antipsychotic use for non-cognitive symptoms in dementia

This Herts Valleys CCG document aims to provide a local and practical approach to the treatment of non-cognitive symptoms in dementia, including guidance on de-prescribing of antipsychotics. It includes:

  • Guidance for prescribers
  • A suggested tapering protocol when reducing and stopping antipsychotics
  • Practical tips on dose reduction
  • Guidance for care practitioners
  • Common side effects of antipsychotic
  • Practical guidance and ideas to support a person with non-cognitive symptoms in dementia

 
The guidance has been circulated to GPs across Herts Valleys CCG.

Administration and Records

Administration in Care Homes

Many authorised care home staff can quickly, safely and securely order their resident’s medications online. This saves the care home, pharmacy and GP practice staff time. It also makes the dispensing of individual medicines easier and creates an automatic audit trail.

To help, the Local Government Association and NHS have published a step-by-step guide. It takes care homes through setting up and granting authorised care home staff proxy access to their resident’s GP online services account.

Administering from Original Packaging

Watch below NHS Herts Valley’s CCG Alison Canning talk about Care Home Guidance for Administering from Original Packs.

» Download the supporting Powerpoint presentation
» Download the supporting document

Other Useful Resources

» Herts Valley CCG: Coronavirus Contingency – Safe Administration of Medicines from Original Packs in Care Homes
» Herts Valley CCG Guidance on recording, maintaining and sharing drug sensitivity/allergy information in care homes
» Herts Valley CCG Medicines Pots Poster v1.0 November 2019

Medication Administration Record (MAR)

Effective record keeping helps ensure that citizens and individuals are always receiving the best possible care and allows for mistakes and concerns to be addressed quickly. Medication Administration Records (MAR) are vital to ensuring staff understand patient’s medical needs and are able to administer the correct medications safely.

Paper based or electronic medicines administration records should:

  • Be legible
  • Be signed by the care home staff or care workers
  • Be clear and accurate
  • Have the correct date and time (either the exact time or the time of day the medicine was taken)
  • Be completed as soon as possible after the person has taken the medicine
  • Avoid jargon and abbreviations

 

» CQC what good looks like for digital records in adult social care
» CQC Guidance about MARs

Bulk Prescribing in Care Homes

Herts Valley Guidance

Bulk Prescribing Guidance for Care Homes Click here
 Bulk Prescribing Order Form (Appendix 1) Click here
Care Home Sign in Sheet for Bulk Prescribed Medication (Appendix 2) Click here
A ‘How to’ Guide for GP Practices Click here

 

East and North Herts Guidance

Bulk Prescribing Full Guidance for Care Homes Click here
 Bulk Prescribing Quick Guide for Care Homes Click here
SOP for Delivering Bulk Prescribing in Care Homes (GP Practice) Click here

 

Webinars

Anticipatory Medication and Bulk Prescribing in Care Homes – Webinar recording 29.04.20 Click here
Anticipatory Medication and Bulk Prescribing in Care Homes – Webinar Slides 29.04.20 Click here

 

Covert Administration in Care Homes

Herts Valley Guidance

East and North Herts

Crushing Tablets/ Opening Capsules in Care Homes

Herts Valley Guidance

East and North Herts

Homely Remedies and Self-Care/ Over the Counter (OTC) in care homes

CQC National Guidance for over the counter Medication and Homely Remedies Click here
Herts Valley Guidance – Homely Remedies Guidance for Care Homes Click here
Herts Valley Guidance: Appendix 2 – Homely Remedy Authorisation Form Click here
Herts Valley Guidance – Homely Remedies Guidance: Appendix 2 – Homely Remedy Stock Control Record Sheet Click here
Herts Valley Guidance: Appendix 4 – Homely Remedy Staff Signature Sheet Click here
Herts Valley Guidance – Prescribing Over-The-Counter Medication to individuals in receipt of Social Care Click here
East and North Hertfordshire – Over-the-Counter medicines resources Click here
East and North Hertfordshire – Self Care Toolkit for Care Homes Click here
East and North Hertfordshire – Homely Remedies Guidance for Care Homes Click here
Homely Remedies Webinar – Slides from the webinar delivered on 14.09.20 Click here
Homely Remedies Webinar – Recording of webinar delivered on 14.09.21 Click here

 

Ordering and Waste Reduction in Care Homes

The care home pharmacy team at Herts Valleys CCG, and East and North Herts CCG, have developed guidance on reducing medicines waste in care homes. The guidance contains key top tips to support care home staff and prescribers to reduce unnecessary medicines waste in care homes, and also includes expiry date guidelines for care home staff. It is important that there are effective systems and processes in place to ensure that medicines are managed appropriately to reduce avoidable medicines waste, and therefore to allow effective use of NHS resources.

The guidance can be found via the following link for CCG guidance. Many factors can contribute to medicines waste in care homes, and a joint effort involving the care homes, community pharmacies and GP practices required. The guidance has been sent to all GP practices and community pharmacies within Herts Valleys CCG. Please share this guidance with all relevant staff within your care home.

» For information on the medication, ordering cycle click here.
» Watch the Bohemian Polypharmacy music video

Useful Resources

Herts Valley CCG – Medication Ordering Cycle for Care Homes Click here
Herts Valley CCG – Medication Ordering Cycle for Care Homes: Appendix 1 – Communication template Click here
East and North Herts CCG – Carrying Medication Forward in Care Homes Click here
East and North Herts CCG – Reducing Medicines Waste in Care Homes Click here
East and North Herts CCG – Setting up Online Ordering of Medication Click here
East and North Herts CCG – Proxy Access Request and Removal of Access Set Up Form Click here
East and North Herts CCG – Care Home and GP SOP Proxy Access Consent Form Click here
East and North Herts CCG – Proxy Access Consent Form Click here
East and North Herts CCG – TPP SYSTMOne User guide for Ordering Medication online by Proxy Access Click here
East and North Herts CCG – Questions and Answers for Care Homes Click here
Waste Reduction in Care Homes – Webinar 02.09.20 Click here
Waste Reduction in Care Homes – Webinar Slides 02.09.20 Click here

 

PRN (When Required) Medication in Care Homes

Re-using Medicines in Care Homes During Covid-19

COVID-19 Associated Documents

Herts Valley CCG – Re-using Medicines in Care Homes and Hospices during COVID-19 – Stage 1: Retention, Quarantine and Agreement Click here
Herts Valley CCG – Re-using Medicines in Care Homes and Hospices during COVID-19 – Stage 2: Administration and Recording Click here
Herts Valley CCG – Re-using Medicines: Form 1 – Consent Form for Residents Click here
Herts Valley CCG: Re-using Medicines: Form 2 – Assessment for Re-Use of a Specific Individual’s Medicine Click here
Herts Valley CCG: Re-using Medicines: Form 3 – Medicines Re-Use Log for Care Homes and Hospices Click here
DoHS – COVID-19 SOP – Running a Medicines Re-Use scheme in Care Homes Click here

 

Re-use of Medication – Webinars

Re-Use of Medicines in Care Homes and Hospices – Webinar 20.05.20 Click here
Re-Use of Medicines in Care Homes and Hospices –  Webinar Slides 20.05.21 Click here
Re-Use of Medicines in Care Homes and Hospices –  Webinar Q&A 20.05.21 Click here
Re-Use of End of Life Medications Part 2 for Care Homes – Webinar 06.08.20 Click here
Re-Use of End of Life Medications Part 2 for Care Homes – Webinar Slides 06.08.20 Click here

 

Reviews in Care Homes

A medication review is a chance for your GP (doctor) and a specialist pharmacist to take a detailed look at the medicines that you are taking, to make sure that they are working well for you and are not giving you any problems. Medication reviews are particularly useful for people who take lots of medicines as they can be at greater risk of having a bad reaction and needing to be admitted to hospital.

Also, as you get older, some of the medicines you have been taking for a while might become less important. For example, if you are over 80 you might not be too concerned about reducing your risk of a heart attack in twenty years’ time and you might not want to have muscle aches, constipation and poor sleep which are potential side effects of statins ‐ common cholesterol lowering drugs.

» Herts Valley CCG – Top Tips for Care Homes Medication Reviews

Deprescribing

  • The number of medicines patients are taking is increasing, driven by the ageing population, multiple prescribers and evidence-based guidelines (usually based on single conditions).
  • For many patients, the potential harms of multiple medicines outweigh the potential benefits, reducing life expectancy and quality of life.
  • Older people and those with increasing frailty are frequently prescribed unnecessary, or higher risk medicines, they should have more frequent medication reviews.
  • Deprescribing is the planned process of reducing or stopping medications that may no longer be of benefit or may be causing harm.
  • The goal is to reduce medication burden or harm while improving quality of life, thus ensuring appropriate polypharmacy and improving patient outcomes.

What happens during a medication review?

Your GP and pharmacist will look at the medicines you take.

They will consider whether:

  • there has been a change in your health or the guidelines on how to treat your condition
  • you are able to take your medicines without difficulties
  • you are taking any unnecessary medicines
  • there is a different medicine which will be just as effective but cheaper for the NHS

Your GP and pharmacist will look at the medicines you take.

What happens next:

Once the team has reviewed your medicines, any changes that are needed will be made slowly and gradually. We will make sure you are told about which medicines are being changed and can answer any questions you may have.

Changes might be:

  • How often you take medicines – for example, taking a tablet once a day rather than three times a day.
  • You might start a new medicine or change to a different version.
  • A medicine being stopped because you no longer need it.

»Download the medication review leaflet here.

To find out more please contact your local CCG Team

The 8 Rights of Medication Administration

One of the recommendations to reduce medication errors and harm is to use the “eight rights” The rights of medications administration are there not only to reduce the harm caused by medications errors but also to protect the interests of the patient and the person administering the medication.

» Click here for full information on the 8 rights

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Vitamin D

The Department of health and social care (DHSC) is providing a free 4 month supply of free vitamin D supplements for care home residents in England. On the 15th January 2021 DHSC issued guidance for Care Home providers about this. Clinical Commissioning Groups have received exactly the same guidance.

Whilst most people get the Vitamin D they need from sunlight, many are serious risk of having a deficiency. Vitamin D is incredibly important for bone health.

» Read more here about Vitamin D supplies and usage here

Useful Resources

NHS –  Vitamin D Easy Read Click here
East and North Herts CCG – Vitamin D FAQ Click here
Herts Valley CCG –  West Herts FAQ Click here

 

Further Guidance

Patches

Different types of medicines are available in patch form; some include painkillers, medicines to treat Parkinson’s disease, and medicines to control nausea and vomiting.

Application of Patches

  • The interval between patches can vary. Patches should be applied at the frequency determined by the prescriber.
  • The site of application should be rotated with each application in accordance with the manufacturer’s instructions. The manufacturer may recommend that the same site should be avoided for a certain length of time. This varies from patch to patch. Always check the patient information leaflet.
  • Patches should not be applied immediately after a person has had a bath or shower, as heat can increase the absorption of some medicines into the bloodstream.
  • Old patches should be removed, folded in half and safely disposed of, before applying a new patch.

Record keeping of Patches

  • The application of a patch should be recorded on the MAR chart.
  • The specific location of the patch should also be recorded. This may be on the MAR chart if there is sufficient space or using another template e.g. a body map or a patch chart.
  • When a patient is transferred between settings, staff should ensure that information around the date, time and site of application, are communicated.

 

Allergies

The recording of drug sensitivity/allergy is important to avoid the inadvertent prescribing, dispensing and administration of an offending drug to the resident. Care home residents are a frail and vulnerable population who are at high risk of adverse drug reactions. There are large discrepancies between drug allergy records, residents care home records, medicines administration record charts and GP medical records. Furthermore, there is no routine system in place for people to keep a record of their own drug sensitivities / allergies. This can lead to confusion over which drugs can be taken safely and can result in residents inadvertently taking a drug they are allergic to.t settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.

» Read full EN Herts CCG guidance here
» Read full HVCCG guidance here

Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients

East and North Herts CCG have recently update their emollient formulary and guidance to ensure best use of NHS resources, all the recommended products are < £5/500g . For residents that have long term conditions that requires regular application of an emollients. Refer to updated guidance.

Epimax® paraffin-Free added as an option following a risk assessment – consider if fire risk is a significant issue e.g. patient prescribed oxygen. The recommended expiry date is 3 months for all products – if this is resulting in waste please ask the GP to review pack size prescribed.

» View further information

Warnings about the risk of severe and fatal burns are being extended to all paraffin-based emollients regardless of paraffin concentration. Data suggest there is also a risk for paraffin-free emollients.

Other Useful Resources

East and North Herts CCG  – Managing acute and urgent prescriptions in Care Homes Click here
East and North Herts CCG – Managing interim prescriptions (non-urgent, mid cycle requests) in Care Home Click here
East and North Herts CCG – GPG CAS Alerts Click here
East and North Herts CCG – Medicines on transfer into Care Home Click here
East and North Herts CCG – List of medications that can contribute to an increased risk of falls Click here
East and North Herts CCG – Safe Handling of High Risk Medicines Click here
Herts Valley CCG – List of medications that can contribute to an increased risk of falls Click here

 

Additional Resources