Snap Shot of Medication Policy & Procedure

Medication Ordering /

Staff to keep copy of all medication requested
Copies of FP10 (prescription) to be kept for each resident. Held in plastic pocket behind individual MAR chart
All drugs received are checked and stock added to MAR chart signed and dated.
Medication must be audited on a daily basis & checking running total balance must be recorded daily
All hand written entries on the MAR chart must be supported by two full signatures & dated.

Administration /

Ensure list of staff signatures & initials is completed (front of MAR folder)
Refused medications reasons must be recorded at reverse of MAR sheet
Constantly refused medication GP to review & to document reason of refusal at the back of the MAR sheet
PRN medication if given thus reason & efficacy must be recorded at the reverse of the MAR sheet
PRN protocol to be completed, copy with MAR & copy and associated care plan placed in individuals care plan folder
Where PRN medication constantly given, GP to review & document outcome.
Should there be changes of medication order staff to obtain new prescription immediately
Ensure dates & times of opening being recorded on the medicine bottle/box and initialled by the nurse.
Covert medication form must be completed & signed by GP & chemist. Should there be any changes of medication to update Covert Medication Form. Assessment of capacity must be completed. Copies to be kept with MAR sheet and within medication part of Care plan.
Staff to observe ‘PROTECTIVE MEALTIME’ policy.
Correct procedure must be followed when administering medications (NO POTTING UP & NO SECONDARY ADMINISTRATION)

Recording /

All MAR sheets must be completely in black ink only.
MAR sheet must show allergies recorded
Where PRN medication administered, homely remedies administered & refused medication reason & efficacy must be recorded at the reverse of the MAR sheet
Where the prescription is for variable dose to specify quantity administered i.e. 1 or 2.
MAR chart must be checked at handover to ensure they are fully completed (NO GAPS)
Carried forward & received drugs must be entered onto the MAR sheet.
Date of expiry of carried forward drugs must be recorded next to the amount carried forward.

Storage /

Temperature & Storage /

Controlled Drugs /

To maintain controlled drug register (Scheduled 1-4)
Controlled drug book index must be updated of the current page number entry
Controlled drugs scheduled 1-4 must be administered, receipt & disposed by two members of staff
All controlled drugs (schedule 1-4) must be stored securely in a locked cupboard within a lockable cupboard (misuse of Drugs Regulations 1973)
All controlled drugs (scheduled 1-4) must be checked by 2 Registered Nurses at the end/start of each shift & documented in the CD book
Controlled drugs must be checked, administered and signed by 2 staff at all times (Registered Nurse & RN/Senior). Recording on CD book and MAR chart with the actual time of administration.
Controlled drugs prescriptions must be photocopied before chemist collects them
Controlled drugs will not be obtained until the actual prescription (FP10) will be collected or received by the chemist or pharmacy.

Disposal /

Medication disposal must be done on a timely manner. (7 days following death of a resident & any extra medication after 28 days cycle must be disposed of within 24hours period)
Staff to use pharmacy disposal book (non-controlled & controlled drugs). Two nurses to sign
Controlled drug disposals must be discarded using the doom kit
Any empty bottles/boxes the label must be taken off prior to disposing them in the bin.
All disposed medication if held on site for any period must be kept secure in a locked room

Oxygen therapy /

Policy/procedure must be available for all staff in the care home covering oxygen administration & storage. This can be found in the clinical room
Oxygen must be prescribed for ‘an individual’ service user
There is a clear signage visible where oxygen is in use (OXYGEN HAZARD & NO SMOKING – OXYGEN IN USE) on the entrance to the home and individual resident room & where oxygen is stored

Information /

Ensure up to date BNF in place & must not be removed from the drug trolley
To maintain MDA folder where drug alerts must be put in treatment room
Medication error must be dealt with openly – reported as per regulation & outcome in line with NMC/Company guidelines
RNs to evidence of ongoing medication training update & assessment of competency

Medication Error Reporting /

Staff to monitor residents vital signs and side effects/contraindications
To report to GP immediately, carry out GP’s order & record in MDT, daily notes & CP Medical Condition/medication care plan & update risk assessment
Call 999 IMMEDIATELY with NO DELAY WERE NECESSARY
An incident report form must be completed attaching staff nurse statement
Report to Home Manager, Clinical Lead, NOK must be informed and recorded on relative communication log. Social Worker must be informed
CQC notification & Safeguarding alert must be completed by Home Manager/Clinical Lead
In correcting error entry on MAR sheet a staff must draw a single line and mark error, sign and date

Staff Name:______
Signature: ______
Date:______/

I HAVE READ & UNDERSTOOD THE COMPANYS POLICY & PROCEDURE OF MEDICATION ORDERING, ADMINISTRATION, RECORDING & DISPOSAL.
I RECEIVED A COPY OF THE SNAP SHOT OF THE COMPANY’S MEDICATION POLICY & PROCEDURE