HANLEY GARDENS AND CALEDONIAN ROAD SUPPORTED HOUSING SCHEME MEDICINES MANAGEMENT PROCEDURE APRIL 2015

Transcription

1 HANLEY GARDENS AND CALEDONIAN ROAD SUPPORTED HOUSING SCHEME MEDICINES MANAGEMENT PROCEDURE APRIL 2015

2 Policy title Hanley Gardens and Caledonian Road Supported Housing Scheme Medicines management procedure Policy reference MP13 Policy category Clinical Relevant to Supported Housing Staff Date published April 2015 Implementation date April 2015 Date last reviewed N/A Next review date April 2018 Policy lead Lucy Reeves, Chief Pharmacist Contact details Telephone: Accountable director Vincent Kirchner, Medical Director Approved by (Group): Lucy Reeves, Chief Pharmacist Joan Bradford, Service Manager Document history Date Version Summary of amendments April New SOP Membership of the policy development/ review team Lucy Reeves, Chief Pharmacist Dana Janowski, Lead Pharmacist Geraldine Groves, Team Manager Consultation Hanley Gardens and Caledonian Road Supported Housing Scheme Staff DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet.

3 Contents Page 1 Introduction 1 2 Aims 1 3 Scope of the policy 1 4 Duties and responsibilities 2 5 Admission 2 6 Prescribing 4 7 Administration and Documentation 5 8 Ordering and receiving medicines 6 9 Clozapine 8 10 Controlled Drugs 8 11 Security & storage 9 12 Disposal 9 13 Pharmacy Service Dissemination and implementation arrangements Training requirements Monitoring and audit arrangements Review of policy Associated documents 12 Appendix 1: Medicines management audit criteria 13 Appendix 2: Equality impact assessment 14 ii

4 1 Introduction 1.1 Camden & Islington NHS Foundation Trust Supported Housing Scheme provides a Rehabilitation and Recovery service to residents with severe and enduring mental health problems. Residents are referred to the supported housing project via the Community Rehabilitation Team. Admissions to the scheme are always pre-planned, with this process usually taking several weeks. 1.2 Location of Supported Houses 4,9,19 and 24 Hanley Gardens, London N4 3DY 471 Caledonian Road, London N7 9RN 1.3 Establishment: Hanley Gardens and Caledonian Road are staffed by mental health practitioners and clinical support workers. Medical support and supervision is provided jointly by the service user s GP and the Community Rehabilitation Team Psychiatrist. 2 Aims To set out clear guidance and procedures to managers and staff for the management of medicines Ensure consistent, high standards of practice across supported housing schemes Ensure safe working practices in the ordering, storage, prescribing, administration and disposal of medicines To minimise risks and ensure the safety of service users and staff. 3 Scope 3.1 This procedure applies to all clinical support workers and mental health practitioners involved in any stage of handling and administration of medicines at C&I FT Supported Housing Schemes 1

5 4 Duties and responsibilities 4.1 The Team Manager has overall responsibility for ensuring staff receive the necessary training and adhere to the procedures in this document. This includes regular monitoring of practice and ensuring any incidents are reported and managed appropriately. 4.2 Clinical support workers and mental health practitioners are responsible for following these procedures and ensuring their knowledge and competencies are kept up to date and any incidents are reported promptly using the approved process. 4.3 Only staff assessed as competent may perform duties having completed the accredited training programme. 5 Admission 5.1 On admission service users are expected to bring their own medication for self administration obtained via their community pharmacy. Service users will be assessed for self-administration following the Self-medication procedure. 5.2 Residents on clozapine may self-administer providing the risk assessment has been done following the Self-medication procedure. The self-administration of all medications must always be monitored by staff. 5.3 Schedule 2 and 3 controlled drugs (e.g. Temazepam) are the exception, and self-administration must always be supervised by staff. The trust CD policy and procedures must be followed. 5.4 Initially the medication must be checked against the GP summary or a discharge summary/discharge notification form if resident is transferred from hospital. 5.5 Within the houses, there will be a member of staff on duty who is responsible for the following: Ensuring the name on the dispensed label corresponds to the resident Ensuring the medication is correct and corresponds to the GP summary/ discharge summary Ensuring that the expiry date is checked and if medication is not in date it should be removed with the consent of the service user. Ensuring there is sufficient medication for the resident. If further supplies are required, the GP must be notified and a prescription obtained, to be dispensed from the community pharmacy. 2

6 Medicines Administration Record (MAR) Chart is provided and completed by the Community Pharmacy. 5.6 The MAR chart for each resident is produced by the relevant community pharmacy and sent with the residents dispensed medicines. The MAR chart should include the following: Name of resident DOB Name of supported housing unit Allergy status Drug name Drug strength e.g. 10mg, 15mg Drug form e.g. tablet, liquid, creams. patches Drug dose e.g. (1g = 2 x 500mg for paracetamol) Drug frequency e.g. once a day, twice a day,three times a day Route e.g. oral, topical Total quantity of medication received 5.7 Following completion of the above checks, all medication must be locked in designated medicines cupboard/refrigerators or individual service users medication lockers. 5.8 All residents self-administer their medication, supervised by a staff member following the Trust Self-medication procedure. 5.9 Only medicines prescribed for the individual resident may be taken by that resident Medicines must be taken by the resident in accordance with the prescription and as documented on the MAR chart The staff member must sign the MAR chart to indicate supervised selfadministration and that ingestion has been observed, or that this has not been achieved (coded accordingly). This must be done immediately after selfadministration of each medicine If the medicine is not taken, due to refusal, wastage or lack of availability, the reason (coded) must be recorded on the MAR chart and in the residents notes. Where a service-user refuses to take their medicines then the House Manager, Team Manager and Care Coordinator should be informed and advice sought. If the medicine is not available then this must be followed up immediately with the dispensing pharmacy and GP as appropriate MAR charts found to have blank administration boxes should be investigated and reported as an incident through the trust incident reporting system The expiry date of all medicines must be checked on admission/receipt. Medicines must not be administered by residents after the expiry date and 3

7 should be disposed of. Certain preparations have a limited expiry once the preparation has been opened and a date opened must be written on the label As required (PRN) medicines must be prescribed and self-administered as directed on the prescription (MAR and label) The as required (PRN) prescription must indicate the dose, frequency interval and maximum dose in 24 hours Where a variable PRN dose is prescribed, then the dose self-administered must be recorded on the MAR chart each time Staff should routinely check if patients require PRN medication. A record should be made when the patient has been prompted but declined PRN medication Self-administration and effectiveness of PRN medicine should be routinely monitored and reviewed. When PRN medicine is repeatedly requested the GP must be notified and a medication review requested. Where PRN medicine is not/infrequently being requested then the prescription should be cancelled or quantity adjusted to prevent unnecessary supplies accumulating or opening e.g. eye drops. The staff member must clearly and indelibly write the date of opening and date of expiry. 6 Prescribing 6.1 All medicines are prescribed using FP10 prescription forms by the resident s GP with the exception of clozapine which is prescribed by the Consultant Psychiatrist using the trust clozapine repeat prescription. 6.2 All medicines must be prescribed for individual named residents 6.3 Only prescribed medicines should be self- administered by residents. 6.4 Medicines are dispensed by the designated community pharmacy(s) 6.5 The GP(s) will provide a prescription for 28 day supply of medicines for each individual resident at the housing scheme on a regular schedule, unless the medicine is an acute need or a specified course of time e.g. antibiotics. Prescriptions are sent directly to the respective community pharmacy for dispensing. 6.6 Any medicines prescribed outside the routine scheduled time (e.g. new medicines or changes to current medicines) should be dispensed and selfadministered by the patient in accordance with the prescription/treatment plan. If the medicine is for continuation then sufficient amount until the next scheduled supply should be prescribed to align with the scheduled supply. 6.7 If any changes to current medicines are made, for example dose adjustment, change in formulation, then a new prescription must be written and dispensed with the correct dose/formulation and administration instructions on the label. 4

8 6.8 Any changes to the prescribed medicines must be clearly documented on the MAR chart in the interim (i.e. until the new MAR chart is issued by the dispensing pharmacy). Amendments to the MAR chart must be checked against the dispensed medicine and FP10 counterfoil and countersigned by another member of staff. 7 Administration and Documentation 7.1 All residents must have a medication risk assessment completed by the team for self- administration using the Trust Self-Administration procedure that is regularly reviewed. Based on the determined level of risk / competence i.e. level 1-3 residents will administer their medication. 7.2 The stage of self administration must be documented on the MAR chart. The staff on duty are responsible for supervising self-administration which must be documented on the MAR chart. Only one person signs the MAR chart. A count must be carried out of the remaining medication daily at the end of the staff shift. 7.3 For each self - administration supervised the following must be recorded: Time Initials of staff Number of tablets (i.e. if they take one or two) 7.4 The following codes are used for administration: Initials =Supervised by staff D= Declined (service user declined medication) O= Omission (should also be documented on Rio) SA= Self administration N= t available F= Any other reason (to be recorded on Rio) 5

9 7.5 Medication which has been discontinued should be crossed through on both the medicine details and the administration record section on the MAR chart. This must be initialed by the staff member of duty. An must be obtained from the prescriber to verify the discontinuation of medicines. This must be filed in the patient s notes and an entry made in the electronic patient record (EPR). 7.6 Service users on depot medication will continue to receive these via the community team staff or their GP surgeries. The community team staff will keep a record of prescribed depot medicine and administration on the trust community medicine chart. A record of the next due depot administration should be kept in the team/house diary. 7.7 Refusal or covert administration: if consent for administration is not given by a resident then staff may not deceive them into accepting medication. It is essential that a distinction is made between those patients who have capacity to refuse medication and those who lack capacity to consent to treatment. 7.8 Where a resident refuses to take their medication the reasons for refusal should be investigated, the GP informed and advice sought. 7.9 If a resident takes too much of their prescribed medication, then the prescriber or trust pharmacist (on-call pharmacist out of normal working hours) must be contacted immediately for advice. If unable to contact either then the resident should be sent to A&E. A datix incident form must be completed. 8 Ordering and receiving medicines 8.1 The GP practice will issue the prescriptions and send to the designated Community Pharmacy. 8.2 The community pharmacy(s) will deliver the medicines to the team. All medicines must be dispensed for individual patients in original packaging or suitable container (e.g. blister packs) and labelled with directions for use. The Community pharmacy will also supply a printed MAR chart for each individual resident. The MAR chart should include all medicines prescribed for the individual resident. The pharmacy should also send the FP10 prescription counterfoil listing all the medicines prescribed. 8.3 The staff member should check the medication against the Medicines Administration Record (MAR) chart and the FP10 counterfoil for accuracy. The FP10 counterfoil should be filed in the service users notes for reference. 8.4 If everything is correct then a record of the check must be made. The staff member must sign and date the MAR chart indicating that the chart and the medicines received have been checked and are correct. The quantities received will be entered on the MAR chart. 8.5 Any discrepancies must be documented and immediately addressed with the designated community pharmacy and/or GP as appropriate. The medicines should be withheld and must not be self-administered by the patient until the discrepancy has been checked and appropriate correction made. 6

10 8.6 The staff member should also check the patient s allergy status in the patient records and record this on the MAR chart. Any concerns with the resident s allergy status and medicine prescribed must be immediately raised with the GP or pharmacist. The medicine must be withheld until confirmed by the GP or pharmacist that it is safe to administer. 8.7 The House Managers are also responsible for monitoring any accumulation in supplies, for example repeat prescribing of PRN medicines in quantities greater then actually required. The GP should be notified and requested to review the prescription. 8.8 For new, discontinued or change in dosage - Interim prescriptions: If the staff member considers there is need for a patient to be reviewed by the GP in between the scheduled visit then an appointment is made with the GP or a referral to the Consultant. If an FP10 prescription is issued to the resident this may be dispensed by a local pharmacy. The prescribed item is added to the MAR chart by staff and checked by another member of staff. A photocopy of the new FP10 prescription must be made and filed with the MAR chart. If a medicine is to be discontinued following review by the GP then a written record of this must be sent and saved in the resident s records / or written directly if the GP is visiting the house. Verbal orders for any changes to prescriptions (e.g. discontinuation, changes in dose, formulation or new medicines) must not be accepted. Trust doctors should record directly in the residents records. 8.9 Arrangements for patients away from the home are as follows: On occasion when the patient needs to take their medicines away from the home, the original dispensed supply should accompany the patient. 7

11 9 Clozapine 9.1 Clozapine is dispensed by the Trust pharmacy at Highgate Mental Health Centre. Clozapine may only be dispensed and taken by patients with a valid blood test result. 9.2 The patient should be taken to the clozapine clinic at HMHC for blood tests. Pharmacy at HMHC will supply the clozapine on receipt of a valid blood result. 9.3 Pharmacy will check the blood results and supply to the resident or member of the supported housing team. 9.4 The dose to be taken by the resident must be checked against the instructions labelled on the boxes supplied to the resident by pharmacy and recorded on the MAR chart. Pharmacy should be requested to supply duplicate labels to be applied to the MAR chart 9.5 A copy of the current clozapine out-patient repeat prescription should be filed in the residents notes 9.6 Any gaps (especially of 48 hours or more) in the resident taking their clozapine must be reported to the consultant/team and pharmacy. 9.7 For more detailed information refer to Trust policy and guidance on clozapine. 10 Controlled Drugs 10.1 Refer to Trust Controlled Drug policy and Controlled Drug SOP for detailed information on storage, handling and record keeping for controlled drugs Controlled drugs must be stored in the controlled drug cabinet and not in patients own locker 10.3 Two members of staff are required to record in the controlled drugs record book when receiving and supervising self-administration of controlled drugs Destruction of controlled drugs should be done on site using the appropriate D.O.O.P kit which is then placed in the medicine waste bin. Destruction of individual patient dispensed controlled drugs may only be done by the trust pharmacist visiting the service and must be witnessed by the team manager or nurse. A record of the destruction must be made in the record book and signed by both members of staff All entries should be dated, signed, timed and witnessed and the balance should be checked at each administration There must be evidence to show that the controlled drug balance is checked on a weekly basis by the team manager and nurse. Pharmacists will then check the balance quarterly. 8

12 11 Security and Storage of medicines 11.1 Detailed information on the requirements for the safe and secure storage of medicines is listed in the Trust Medicines Management policy and must be followed Medicines must be stored in locked medicines cupboards except for residents on stage 3 self-administration. In this case, medicines will be stored in a locked medicines cabinet in the resident s room Medicines requiring refrigeration (marked store in fridge or store between 2 C - 8 C ) must be stored in a locked refrigerator used only for the storage of medicines. The temperature must be kept between 2 C - 8 C and checked every working day using a digital maximum/minimum thermometer. The minimum, maximum and current temperature must be recorded on the trust refrigerator monitoring form. If the reading falls outside this range the trust pharmacy must be contacted for advice regarding the further use of the medicines stored within. Any medicines stored in the refrigerator should be transferred immediately to another refrigerator. These medicines must be quarantined (i.e. separated from other medicines and clearly marked not for use ) until pharmacy have advised if further use is appropriate or disposal necessary Keys for the medicines room, medicine cupboards, medicines refrigerator and controlled drugs cupboard must be held by the staff member in charge and kept separately from other keys. The controlled drug cupboard keys should be separate from the other medicine cupboard keys. Medicine keys must be handed over to the staff member in charge at each shift change. 12 Disposal of medicines 12.1 Detailed information on the requirements for disposal of medicines is listed in the Trust Medicines Management policy and Trust Waste Management policy Medicines prepared ready for administration, or removed from the original container, but not used (including open ampoules) must be discarded into a sharps bin (yellow lid) All medicines (except controlled drugs and cytotoxic medicines) date expired or no longer suitable for use should be discarded into a blue pharmaceutical waste bin in their original container or packaging Cytotoxic/cytostatic medicines must be disposed of separately to other medicines in a purple lidded container. Trust pharmacy should be should be contacted for further information in the event of such medicines being used at the service Controlled Drugs that are time expired, no longer fit for use, or no longer required on the ward, must be destroyed using a denaturing kit. The used 9

13 denaturing kit must be stored in the CD cupboard before disposing of in blue medicines waste bins All expired medication should be logged in a record book designated for this purpose. It should include the name of the drug, name of the resident, quantity, reason for disposal and signature of the staff member disposing the medication. 13 Trust Pharmacy service 13.1 The trust pharmacist will visit on a monthly basis to provide a clinical pharmacy service, including review of prescribed medicines and MAR charts, and to support the safe and secure handling of medicines. The pharmacist is also available to provide medicines information advice, support and training for staff and counselling to residents as required. Highgate Mental Health Centre opening hours are 9.00am 5.15pm Monday- Friday. The Whittington hospital pharmacy (weekend service) is open 10am-2pm Saturday-Sunday The On-Call pharmacist may be contacted outside these hours via Whittington hospital switchboard for urgent/emergency advice. 14 Dissemination and implementation arrangements 14.1 This document will be circulated to all staff within the team, involved in the handling of medicines. It will be available to all staff via Trust intranet. Managers must ensure that all staff are briefed on its contents and understand what it means for their practice, as part of their responsibility. 15 Training requirements 15.1 All staff must successfully complete the local induction period of supervision and complete a course in medicines management The manager will have responsibility to use the competency assessment tool to assess clinical support workers and maintain all records. 10

14 16 Monitoring and audit arrangements 16.1 Compliance with this Medicines Management procedure will be monitored monthly by the Team manager. Criteria to be monitored are listed in appendix Safe & secure handling of medicines and controlled drugs will be audited through the Trust Medicines Management annual audit programme. Required actions will be identified and completed in a specified time frame. Elements to be monitored Lead How trust will monitor compliance Frequency Reporting arrangemen ts Which committee or group will the monitoring report go to? Acting on recommendations and Lead(s) Which committee or group will act on recommendations? Change in practice and lessons to be shared How will changes be implemented and lessons learnt/ shared? Handwritten entries on MAR, signed by two support workers Blank spaces on MAR to checked if missing GG Audit Monthly Operatioanl Manageme nt meeting(o MM) monthly) GG Audit Monthly As above Suggested wording Required actions will be identified and completed on a monthly bases Individual 1:1 with l staff members and discussion at team meeting. Dispensed medication are checked against the MAR chart and original GP FP10 counterfoil / clozapine outpatient prescription DJ/GG Audit Monthly As above 17 Review of the policy Two years, April

15 18 Associated documents Trust Medicines Management Policy Trust Controlled Drug Policy Trust Controlled Drug Standard Operating Procedure (SOP) Trust Covert Administration of Medicines Policy. Trust Self-administration procedure 12

16 Appendix 1 Medicines Management Audit Criteria These criteria should be checked monthly by the designated staff members. Results of the audit checks will be monitored by the team manager. Required actions will be identified and completed in a specified timeframe. a) Dispensed medicines and MAR checked against FP10 counterfoil on receipt. Each medicine has been signed and dated as checked by designated staff member. Where medicines are not signed as having been checked there is a documented reason and action taken. b) Any hand written entries on MAR chart are signed and dated by two designated staff members on shift (unless written by GP). c) Medicines administration is recorded or reason for not administering (by code) on the MAR. There are no blank spaces on at due times for administration. d) Number of medicine units (i.e. tablets/capsules) remaining reconciles with records of administration. Where there is a discrepancy the reason has been documented and action taken. e) PRN medicines have been administered in accordance with prescription. Where being given regularly the GP has been requested to review. f) Controlled Drug balance in stock and record book correct. All entries in controlled drug record book in accordance with standards set out in Trust Controlled Drug Standard Operating Procedure. g) Where necessary the date of opening has been written on the label of the medicine. The do not use by date is also clear. h) All medicines being administered are in date. i) All medicines are stored appropriately in locked medicines cupboard, CD cupboard or medicines fridge. j) Fridge temperature is monitored daily and appropriate action taken where temperature has deviated outside 2-8 degrees C k) Rooms where medicines are stored are temperature monitored daily and appropriate action taken where temperature has deviated above 25 degrees C. l) There is an up to date log of all disposed medicines. 13

17 Appendix 2 Equality Impact Assessment Tool Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A N/A N/A 14