Information required before staff may assist with medication

Medication risk assessment

6.1    We will not provide support with medication until we have carried out a risk assessment of medication related risks (including how medication will be stored) and determined that support is necessary.  We will record the outcome of the risk assessment in the person’s plan.

6.2    Wherever possible and safe, we will support people to become more independent with their medication. This may involve a trial period monitored by staff during which the person manages their own medication. We will review the trial immediately if the person or other people using the service are at risk of harm. 

6.3    We will keep risk assessments under review and re-assess risks as appropriate, for example before off-site activities; at any time when there is any doubt about the person’s ability to take their medication as prescribed and / or store it safely; when the person is being discharged or is transferring to another service. 

Capacity and consent 

6.4    We will not provide support with medication until the person has provided their written consent for us to do so. Consent may in some circumstances be provided by a representative or support with medication may be agreed as a best interest decision.  

People aged 16 years and over

6.5    We will assume that anyone who is 16 or over has capacity to provide consent.  If there are doubts about a person’s capacity to consent, a capacity assessment will be undertaken. 

6.6    Where we have determined that the person lacks capacity, consent may be provided by anyone authorised under the Mental Capacity Act to make personal welfare decisions on their behalf.   If there is no such person, we will follow the Mental Capacity Act (MCA) Policy | Gloucestershire County Council to reach a best interest decision.

Children aged under 16 years

6.7    Children who are aged under 16 may provide consent if they are competent to do so. Otherwise, consent may be provided by someone with parental responsibility or the court.

Plan 

6.8    We will record in the person’s plan:

• whether or not the person requires support to safely manage their medication
• the exact nature of any support required from staff and where relevant any staff monitoring responsibilities, for example when someone is managing their own medication including during a trial or reablement period. 

6.9    We will review and update the plan at regular intervals and whenever there is any change to:

• the person’s health, care or medication support needs
• the support or monitoring required from staff

Essential medication information

6.10    All medication may cause harm if it is not administered according to the prescriber’s or manufacturer’s instructions.  We will not provide support with medication until we have all the information set out in this section. 

6.11    Staff must immediately update the information whenever there is any change to:

• the person’s medication, for example when a medication is started, stopped or a dose is changed
• the support required from staff

6.12    All medications – the person’s record must include these details.

• the full name and date of birth of the person to whom medication is to be administered 
• any known drug sensitivities e.g. to penicillin, aspirin  
• the name of the medication to be administered
• the reason why the person is taking the medication
• the form of the medication e.g. tablets or liquid  
• the amount in the bottle/container supplied to the home/day centre
• the strength of the preparation  
• the required dose  
• the route of administration e.g. by mouth  
• the time(s) the medicine is to be administered  
• any special instructions e.g. whether it should be given before or after food 

6.13    As and when required medications – the person’s record must include these additional details: 

• the circumstances in which the medication is to be given
• how much medication is to be given 
• what the medication is expected to do, for example help them breathe more easily
• whether a dose can be repeated and if so:
• • the minimum time between doses if the initial dose has no effect, and
  • the maximum dose which can be taken within 24 hours. 

6.14    Variable dose medications - Prescribers may alter the dose of a variable dose medication following a blood test. 

6.15    If the person has had a blood test and no advice has been received from the prescriber, staff must check with the prescriber to see if the dose has changed. If it has, staff must ask the prescriber to confirm the correct dose in writing and update the person’s record.

6.16    Over the counter products – These may be provided for general use in some services or may be brought into the service by family.  

6.17    Staff must check with the person’s GP or a pharmacist about whether an over the counter product might interact with a prescribed medication.   Staff must record the advice in the person’s record and where relevant discuss the advice with the person and/or their family.