Medication Management

Medicines support carries more day-to-day risk than almost anything else care workers do. Most of the time nothing goes wrong — which is exactly the danger, because routine breeds shortcuts: signing the MAR before the tablets are swallowed, popping tomorrow morning's dose "to save time", giving from memory rather than the chart. Every serious medication incident report contains a shortcut that had worked fine a hundred times.

The level of support varies: some people just need a prompt ("it's tablet time"), some need assistance (opening the blister, steadying a hand), and some need full administration. Know which level each person is assessed for, because the responsibility and records differ. In domiciliary care especially, be precise about what you are and aren't commissioned to do with medicines.

Two principles carry you through nearly everything. First, the chart is the truth: if it isn't on the MAR, it didn't happen; if it's on the MAR, it must have happened. Second, when anything is unclear — a missing dose, an unfamiliar box, an unreadable instruction — stop and ask. Nobody was ever disciplined for phoning the pharmacist.

• Regulation 12(2)(g): the proper and safe management of medicines is an explicit part of safe care and treatment.
• Medicines Act 1968 / Human Medicines Regulations 2012: the framework for prescribing, supply and administration.
• Misuse of Drugs Act 1971 and Regulations 2001: controlled drugs — storage (safe custody in care homes), records in a CD register, witnessed administration and denaturing before disposal per local policy.
• NICE SC1: managing medicines in care homes — ordering, receipt, storage, administration, records, reviews.
• NICE NG67: managing medicines for adults receiving social care in the community — including defining levels of support and provider responsibilities.
• MCA 2005: capacity and consent for medicines; covert administration only via best-interests processes.

Medicines are scrutinised at almost every assessment: MAR audits (gaps, codes used properly, handwritten entries double-signed), storage and temperatures (including fridge logs), CD registers and balances, PRN protocols that actually guide decisions, staff competency assessments, and what happened after errors. CQC expects a culture where staff report errors quickly and the service responds with learning — repeated hidden errors found in an audit are far more damaging than reported ones handled well. Medicines reconciliation on admission and after hospital stays is a frequent weak spot.

• Prepare the round: right MAR, meds in original packaging or MDS, no distractions — interruptions are the biggest single error factor. Some services use "do not disturb" tabards for good reason.
• Check the six rights against the MAR and the label, give, watch it taken, then sign. Use the correct code (refused, hospital, nausea…) when not given — an empty box is an unexplained gap.
• Time-critical medicines (e.g. Parkinson's) get planned first, not fitted in.
• PRN: check the protocol and the last dose before giving; record effect afterwards. Rising PRN use is a review trigger, not a routine.
• Refusals: respect, record, monitor, and escalate patterns to the GP — never hide a tablet in food on your own initiative; covert routes need the full MCA process with prescriber and pharmacist, written into the plan.
• Errors and near misses: person first (check them, call 111/GP/999 as advised), then honesty — manager informed, MAR annotated factually, incident form completed, duty of candour where it applies, and a team huddle on the lesson.
• Keep lists current: allergies visible, medicines reconciled at every transition, disposal recorded.

Example 1. Halfway through a busy morning round, a senior realises the MAR she signed shows 8am amlodipine given — but the pot still holds a white tablet. She stops the round, checks the resident (well, no doubling), corrects the record with a dated note rather than an overwrite, completes an incident form, and raises interruptions at handover. The service later moves phone-answering off whoever holds the keys. Near miss, honestly handled, system improved.

Example 2. A home care client with dementia has started refusing her evening antipsychotic, and a relative suggests "just put it in her yoghurt". The worker explains she can't do that, records the refusals, and flags it to the coordinator. The GP reviews — and actually deprescribes, preferring non-drug approaches to her distress. The refusal triggered exactly the review the law intends; yoghurt would have hidden the question for months.