Operational Guidelines: when Service Users require assistance with medications from Domiciliary Care Workers. Version 3

Operational Guidelines: when Service Users require assistance with medications from Domiciliary Care Workers Version 3 CLINICAL GUIDELINES ID TAG Operational Guidelines: when service users require assistance with medication Title: from Domiciliary Care Workers Author: Elizabeth Smyth Speciality / Division: Directorate: Pharmacy Date Uploaded: April 2018 Review Date Clinical Guidelines ID: Older People and Primary care Mental health Learning Disability Physical Disability April 2020 CG0078[2] 1

Contents Topic Page(s) 1.0 Introduction 3 2.0 Support with Medication 3 2.1 Background 3/4 2.2 Levels of Support 4/5/6 2.3 Support 6 2.4 Management Responsibilities 6/7/8 2.5 Documentation 9/10/11 2.6 Permissions/ Consent 11 2.7 Limitations of Domiciliary Care Workers Role 11/12 2.8 Liquid medications 12 2.9 Transportation of Prescribed Medications 12 2.10 As and when required Medications (PRN) 12/13 2.11 Special Storage Arrangement 13 2.12 Medication Errors 13 2.13 Allergies to Prescribed Medication 13 2.14 Disposal of Unwanted Medications 13/14 2.15 Medicines for Later 14 2.16 Service Users Refusing 14 2.17 Complex Medicines Regimes 14 2.18 Controlled Drugs 14 2.19 Thickeners 14/15 2.20 Where two agencies are involved in medicines administration 15 3.0 Specific Medicines Procedures 16 3.1 Background 16 3.2 Specific Medicines Procedures 16/17 3.3 Specific Medicines Procedures, which Domiciliary Care Workers are 17 not permitted to Perform 3.4 Procedure for Domiciliary Care Workers (DCW) applying 17 creams/ointments/lotions/spray References 18 Appendices 2

1.0 Introduction Changes and development of care in the community has resulted in more people with higher dependency being cared for at home. Some of these people may require support with taking their prescribed medication or with performing a specific medicines procedure; for example applying eye drops or medicated patches. These Guidelines have been set out by the Southern Health and Social Services Trust and are in accordance with RQIA guidelines (2009, 2012). Their purpose is to guide Key Workers, Domiciliary Care Supervisors, Community Nurses and Domiciliary Care Workers when support with prescribed medications is commissioned. They outline how domiciliary care staff can support service users with their oral medication: section 2.0 or perform specific medicines procedures: section 3.0 and set out the parameters as to what a Domiciliary Care Worker can and cannot do. Support will only be provided after the Domiciliary Care Worker has undergone medicines management training and has been deemed competent performing the agreed tasks. Whilst these guidelines are developed for Trust employed Domiciliary Care Workers the Trust would request that Independent Sector Domiciliary Care Agencies contracted to provide domiciliary care by the Trust would incorporate them as best practice. Terms: Domiciliary Care Supervisor Within the document where it refers to a Domiciliary Care Supervisor this would also refer to Domiciliary Care Workers direct line manager in an independent Domiciliary Care. Agency Community nurse Where the term Community Nurse is used, this refers to a Learning Disability Nurse/ Mental Health Nurse/ District Nurse/ Specialist Nurse working in the community across all directorates in the Southern Trust. The Southern Trust will not accept responsibility for medication given to service users or specific medicines procedures carried out in their own homes by any person not employed or contracted by Southern Health and Social Services Trust The Southern Trust will not accept responsibility for domiciliary care staff working outside their role i.e. carrying out duties not detailed in the home documentation/care plan. 2.0 Support with Medication NB. Support with medication will only be provided when all other options have been explored and there is no other means of the service user managing their own medication. 2.1 Background The majority of service users in receipt of Domiciliary Care services will be responsible for managing their own medication. It is important that service users are encouraged to maintain their independence in this activity of daily living. The Southern Trust is committed to the basic principle that service users should be supported and empowered to exercise maximum personal responsibility over their own lives and decisions, as appropriate to their capacity. Where there is a concern that a service user is not capable of self-medication the issue will be managed in the first instance by the Key Worker. 3

It is the community Key Workers* responsibility to ensure that a face to face assessment is carried out and Part A of the Medication Assessment Tool (Appendix 1) or Domain 4 of NISAT is completed. *The key worker may be a Social Worker, Occupational Therapist, Community Nurse or in MHD a Case Manager. Assessment will involve exploring all possible interventions that can be utilised to support and empower service users and their families to maximise their personal responsibility to maintain their independence with this activity. Discussion must take place with family members/ carers/ significant others to ascertain their level of support to assist the service user with their medicines. It must not be assumed that just because a service user is in receipt of a care package including assistance with personal care and toileting four times a day; that they will also require assistance with their medicines. Interventions by the assessor to maintain independence may include liaising with the pharmacist to provide larger labelling, easy opening containers, or provision of a Monitored Dosage System. Demonstration on how to open Monitored Dosage System over a bowl may be all that is required to enable a service user to retain independence with their medications. Where a more detailed assessment is required a referral will be made to Community Nursing for completion of Part B of the Medication Assessment Tool (Appendix 1). See Decision Tree (Appendix 2) for summary of actions. This assessment will determine the level of support required. 2.2 Levels of support Level 1 Level 1 support is where following assessment; medicines can be managed without a commissioned service. It is only when the service user cannot be managed at level 1 and where all options have been exhausted, that a potential commissioned service should be considered. NB: This equates with level 1 of Domain 4 of the NISAT Tool. There are 2 levels of support that domiciliary care staff can facilitate: Domiciliary care staff must only assist with medication at the level detailed in the home documentation/care plan. Level 2 - assist At level 2 the Service user maintains control of their prescribed medications but requires assistance in the form of physical manipulation of a container. For example opening a bottle or popping tablets or capsules out of a blister pack at the request of the service user (due to physical problems e.g. dexterity). The Domiciliary Care Worker requests that the service user selects the medication bottle/container and the worker must not direct the service user which medication or what dose to take. These tasks must have been agreed and consented to and a level 2 Medication Care Plan completed specifying the exact action to be taken by the Domiciliary Care Worker (Appendix 3). Level 2 does not include prompting. There are many reminder aids available such as text or phone reminders, reminder watches and clocks and pill reminders which the service user/family member/carer/significant other can be directed to. Level 2 does not include supervising. 4

Level 2 does not include applying creams, eye drops, ear drops or patches etc. Level 2 does not include putting the tablets into the service user s mouth. Level 2 assistance can be organised by a Key Worker of any profession. All tasks must be completed within the presence of the service user and the service user retains responsibility for their medicine management. There is no need to record which medications have been opened on the Medicines Administration Recording Sheet. Assistance given by domiciliary care staff must be recorded in the service user s notes for example opened Mrs Smyth s medicine bottle. Domiciliary care Workers must report any concerns to their Domiciliary Care Supervisor/on call. NB: Level 2 support equates with level 1 of RQIA Guidelines for the Control and Administration of medicines - Domiciliary Care Agencies (RQIA, 2009) NB: Level 2 equates with Levels 2 and 3 of Domain 4 of the NISAT Tool. Please note the service user cannot be assisted at two different levels at the same time e.g. level 2 for oral medicines and level 3 for creams etc. Referral to Community Nurse The service user must only be referred to community nursing where Part A or NISAT Domain 4 has been forwarded and there is sufficient evidence that all avenues have been pursued and; none of the possible interventions will enable the service user to be level 1, level 2 support will not meet the service user s needs, there is no family member/ carer/ significant other available to support the service user with their medications. Where an onward referral to community nursing lacks sufficient evidence that a full assessment has been carried out and all possible interventions explored, it will be directed back to the Key Worker for them to complete. Level 3- administer Where an appropriate referral has been received by the community nursing team (following the local referral pathway); the Community Nurse will complete Part B of the Medication Assessment Tool. This will explore further options as outlined in the Tool and the supporting guidance. At level 3 the service user is unable to take responsibility for the management of their prescribed medications and requires the Domiciliary Care Worker to administer medications from the original container or a sealed pharmacy filled Monitored Dosage System (MDS). If administering from a sealed pharmacy filled MDS there will be labels on the MDS corresponding to the medication contained within the unit provided by the pharmacist. The Community Nurse will have given permission to administer from the MDS on the Medication Instruction Sheet. If administering from original containers the Domiciliary Care Worker will give the medications as individually detailed on the Medication Instruction Sheet completed by a Community Nurse. The Domiciliary Care Worker will record what has been given on the Medicines Administration Recording Sheet. NB: Level 3 support equates with level 2 of RQIA Guidelines for the Control and Administration of medicines - Domiciliary Care Agencies (RQIA, 2009) NB: Level 3 equates with Level 4 of Domain 4 of the NISAT Tool. 5

Where a service user is being assisted at Level 3 the community pharmacist should be informed by the community nurse. Changes The different levels of support should be considered as a continuum, accepting that service users may move up or down the levels depending on their health status and/ or functional ability at the time. Where the service user s needs change this will be managed in the first instance by the Key Worker reviewing the initial assessment, Part A of the Medications Assessment Tool or Domain 4 of the NISAT Tool, and where appropriate referred to community nursing for reassessment Part B of the Medication Assessment Tool (Appendix 1). It is important that any change in the service users ability to manage his/ her own medication is reported to the Domiciliary Care Supervisor for onward reporting to the Key Worker as soon as possible. Review The key worker should ask the person who completed the assessment and subsequent documentation for an update which will contribute to the annual review. 2.3 Support The Domiciliary Care Workers will only be permitted to support with prescribed medication when: 1. They have received training in medicines management. (For Trust employed domiciliary care staff this will be provided by the Medicines Management Nurse). 2. They have been deemed competent. (For Trust employed domiciliary care staff four key skills will be taught and assessed by Management Skills Assessments (MMSA). Competency will be reviewed yearly. MMSA include; assistance with oral medicines, instilling an eye drop, applying a cream and applying a medicated patch.) See Education and Training Competency Framework for non-nursing staff working in Domiciliary Care and Day Care, Residential Care and Supported Living settings. This is located on the Trust Intranet Clinical Guidelines Repository Site by typing in a key word www.southernguidelines.hscni.net. 3. The task of supporting with medication has been delegated by their Domiciliary Care Supervisor as recommended following assessment 4. The exact nature of the support has been specified in the care plan i.e. a level 2 Medication Care Plan for level 2 assistance, a Medication Instruction Sheet for level 3 assistance 5. Domiciliary Care Workers are responsible for reporting any changes to their Domiciliary Care Supervisor 2.4 Management Responsibilities Registered Managers are responsibility for: Ensuring all Domiciliary Care Workers have core medicines training and completed Medicines Management Skills Assessments before assisting with medicines and records of training are maintained. Ensure all Domiciliary Care Workers have a yearly medicines refresher and review of competency via the Medicines Management Skills Assessments and records of training are maintained. 6

Ensure Domiciliary Care Supervisors and OOH Shift Managers have had core medicines training and have completed additional medicines training/ competency for supervisors. Ensure all medicines incidents are investigated and appropriate action taken. Support Domiciliary Care Supervisors in liaising with appropriate professionals where medicines regimes are complex. Reporting medicines incidents via Trust Datix and to RQIA as appropriate Domiciliary Care Supervisors are responsible for: Ensuring that domiciliary care staff are appropriately trained and deemed competent for any delegated task involving support with medication and for keeping a record of training and competency assessments. Supporting domiciliary care staff who have failed the MMSA and preparing them for reassessment Monitoring Domiciliary Care Workers and highlighting any issues to their line manager and Key worker/ Community Nurse concerned. Monitoring must include the care workers ability to record on Trust documentation. Ensuring that Domiciliary Care Workers are not undertaking inappropriate tasks. Liaising with the Key Worker/ Community Nurse or other health professionals e.g. GP or Pharmacist regarding any queries. Supporting Domiciliary Care Workers to administer medicines out of hours see section 2.5 Out of Hours arrangements. Providing advice and support to Domiciliary Care Workers with regard to medication queries. Complete the Trust Datix system when a medication error/ incident occurs, informing RQIA (if appropriate) and complete an Action Plan for the worker/s concerned where appropriate. Key Workers are responsible for: (the Key Worker may also be a Community Nurse) Carrying out a face to face assessment to complete the first part of the Assessment Tool Part A (Appendix 1) or Domain 4 of the NISAT Tool when a concern is raised regarding a service user managing his/her medication. Directing service users family members/ carers/ significant others to possible interventions that will enable the service user to retain independence with their prescribed medicines. Liaising with family members/ carers/ significant others as appropriate to ascertain what support they will provide. Where appropriate request families/ carers/ significant others to liaise with the pharmacist regarding possible solutions that will maintain independence for example larger labelling, easy opening containers, pill box reminders or provision of a MDS. 7

Where level 2 assistance is commissioned; completing the Level 2 Medication Care Plan, ensuring that the care plan gives the specific instructions for the domiciliary care staff, for example opening a bottle or popping tablets or capsules out of a blister pack at the request of the service user (Appendix 3). Where all avenues have been explored and a more detailed assessment is required, referring to community nursing to complete part B of Medication Assessment Tool (Appendix 1). Monitoring and reviewing the care package to identify any changes. Where appropriate completing the OTC creams procedure for Private agency Domiciliary Care Workers as per section 3.4. Community Nurses responsibilities (if not the key Worker) Carrying out a more detailed medicines management assessment/ reassessment when required completing part B of the Medication Assessment Tool (Appendix 1). As part of this assessment determining the complexity of the medicines regime i.e. considering the number of medicines to be given out of original containers, the number and complexity of liquid medicines etc. See 2.17, Southern Trust definition of complex medicine regime. Where the medication regime is too complex to be delegated to domiciliary care staff; liaising with the GP/ Pharmacist regarding simplifying the regime and/ or liaising with family/ community nursing teams to explore other options. Referral to Managing Your Medicines Scheme or Medicines Use Review may assist in reducing complexity. For details on Managing Your Medicines Scheme go to http://www.hscbusiness.hscni.net/pdf/a1-_description_of_service.pdf For details on Medicines Use Review go to http://www.hscbusiness.hscni.net/services/2427.htm Where level 3 support is required, ensuring that the Medication Instruction Sheet is completed and updated as necessary. Where medications are in liquid form and require to be measured in an oral syringe; ensuring that the correct size of syringe is available. Where the neck of the bottle facilitates a bung; ensure this is obtained and observe the Domiciliary Care Workers carrying out this task to ensure competency. Where a specific medicines technique is to be carried out e.g. instilling an eye drop, ensuring the procedure is patient specific and inserted into the service user s care plan Where a specific medicines technique is to be carried out that training is not covered in MMSAs e.g. ear drops; the community nurse will ensure Domiciliary Care Workers are trained/ competent to carry this out. Where a service user s medication requires safe storage; liaising with the family members/ carers/ significant others to ensure a safe system is in place. 8

2.5 Documentation Level 2 Medication Care Plan It is the responsibility of the key worker to complete the Level 2 Medication Care Plan for the specific actions for level 2 (Appendix 3). Medication Instruction Sheet Southern Trust domiciliary care staff will not administer medication unless the Medication Instruction Sheet is completed and in the care plan. Where medications are to be administered out of an MDS, column 1 must be completed by the Community Nurse for the relevant times of day as per the Transcribing Procedures (2015). See diagram 1. THIS IS NOT TRANSCRIBING. Diagram 1 Where medications are to be administered out of the original container i.e. liquids, sachets or tablets that are not suitable for inclusion in an Monitored Dosage System, or for creams, eye drops inhalers, patches etc., the community nurse records the details of the specific medicine in columns 2 and 3 as per the Transcribing Procedures (2015). See diagram 2. THIS IS TRANSCRIBING. Diagram 2 Please note: - The example Medication Instruction sheet in diagram 2 is for example only and contains 6 medicines out of the original container at breakfast time which would be defined as complex as per section 2.17. - There must only be 1 Medication Instruction Sheet in a service user s care plan at any time. - - The Medication Instruction Sheet must be in colour and is available to order from Peninsula Print ref number 22386 HM02. 9

It is the responsibility of the Domiciliary Care Worker to report any changes in a service user s medication immediately for example if a medication has been stopped or a new medication is commenced to ensure the Medication Instruction Sheet is amended. Any amendments must be recorded on the MIS by the community nurse before the DCW can assist with the exception of out of hour s arrangements as detailed below. Support for community Nurses The Trust Transcribing procedures (2015) provide clear guidelines for Community Nurses and are located on the Trust Intranet Clinical Guidelines Repository Site by typing in a key word www.southernguidelines.hscni.net. All community nurses must have completed the transcribing E Learning training and this must be refreshed yearly. A5 laminated guidance is also available from Team Leaders for community nurses to keep in their diary as an easy reference. Out of hours arrangements for completing the Medication Instruction Sheet In exceptional circumstances where a service user is already receiving level 3 assistance with their medications and a new medication (oral medicine, eye drop or cream) is prescribed over the weekend or evening for example an antibiotic, the Domiciliary Care Supervisor can give permission for a Domiciliary Care Worker to administer this medication until a Community Nurse can record this on the Medication Instruction Sheet. See Flow Chart for arrangements when Domiciliary Care Workers are requested to administer prescribed medication outside normal working hours for interim period (Appendix 4). Medication Administration Recording Sheet When domiciliary care staff are supporting the service user to take their prescribed medication at level 3, a record of this must be made on the Medicines Administration Recording Sheet, showing the date, time and staff signature. Where medications are administered from a MDS, the number of tablets/capsules and from which section they were removed e.g. Tuesday breakfast (6) must be recorded. Where medications are administered out of original containers, domiciliary care staff must individually record all medicines administered. See Diagram 3. Diagram 3 10

Where two Domiciliary Care Workers are involved Where two Domiciliary Care Workers are required to provide care to a service user e.g. two for hoisting, the Domiciliary Care Worker who is taking responsibility for the medicines administration should record what has been given and sign the Medication Administration Recording Sheet. Where it is specified that both Domiciliary Care Workers are involved in preparation and administration of the medication, both should be involved in all aspects of preparation and administration and both sign the Medication Administration Recording Sheet. 2.6 Permission/ Consent At the initial assessment consent to having support with medications must be discussed with the service user or their representative and recorded in their notes. 2.7 Limitations of Domiciliary Care Workers Role Domiciliary Care staff must not: Administer any medication not listed on the Medication Instruction Sheet if out of original containers (unless exceptional circumstances out as outlined in 2.5) Administer medication where the label on the medication does not match the Medication Instruction Sheet. Where there is any concern the Domiciliary Care Supervisor should be contacted for advice. Amend or alter the Medication Instruction Sheet in any way. Administer medications out of an unsealed compliance aid. Administer medications where there is not a 4 hour gap between the previous medications. Where there is any concern the Domiciliary Care Supervisor should be contacted for advice. Force or coerce the service user to take medications when after encouragement they directly refuse. Assist with or administer over the counter or other medication that has not been prescribed, unless it is an over the counter cream on the agreed list and the care plan for creams/ ointments/ lotions/ sprays purchased by service users or their families is in the home documentation as outlined in section 3.4. Dispose of more than the dose of medicines for one administration time for example morning medications. Fill compliance aids for service users. Assist with preparation of/ or administer insulin. Assist with oral medication administered via a pump e.g. Ebixa. Assist with medication where the medication is a titrating dose from the original container or a titration blister pack that does not have the days and dates clearly identified. Administer medication that the dose changes frequently e.g. warfarin unless the Warfarin is in a sealed medication aid. 11

Crush prescribed tablets or open capsules unless specified in the care plan (as agreed by the pharmacist) Administer prescribed medications covertly unless specified in the care plan (as agreed by the multi - disciplinary team) Administer medication into the vagina, rectum or bladder. Offer advice or recommendations regarding medication. Take on a delegated medication task that they have not been trained and deemed competent in. Any training needs must be highlighted to Domiciliary Care Supervisor. Collect prescribed medications unless on rare circumstances when instructed to do so in the care plan. Where this is a designated task, the Domiciliary Care Worker must carry their ID and ensure their own safety. The Medication must be taken without delay to the service user and not left unattended in the Domiciliary Care Worker s car. Administer medications where they have any concern they must contact their supervisor. For service users where there is a history of alcohol or drugs misuse a risk management plan must be in place to guide the Domiciliary Care Workers concerned. 2.8 Liquid medications When domiciliary care staff are commissioned to administer liquid medication, the correct measuring cup/spoon must be used. Where a liquid medicine needs to be measured in an oral syringe the correct size of oral syringe must always be provided (by the pharmacist) e.g. if less than 1 ml, a 1 ml oral syringe must be provided, between 3-5 mls a 5ml oral syringe. Domiciliary care staff can administer more than one liquid medication where it is measured in a medicine cup, however they are only be allowed to administer ONE liquid medicine that has to be measured in an oral syringe and must be observed and deemed competent carrying out this task by a Community Nurse. Where more than 3 liquid medicines have to be administered at any administration time this is deemed complex as per section 2.17. 2.9 Transportation of Prescribed Medication Domiciliary care staff are not allowed to collect medications for service users (except in rare exceptional circumstances as discussed in 2.7). Where there is no family member/ carer/ significant other available to collect medications, service users will be directed to avail of pharmacy home delivery services. The key worker will explore this option with the family. 2.10 As and when required Medication (P.R.N.) For example: Painkillers, Cough Mixture Domiciliary care staff must only ever administer as and when required medication when it is clearly written up in the Medication Instruction Sheet with detailed instructions as to when it should be given including the minimum interval between doses and maximum dose in a 24hour period. The service user must have the ability to decide and to communicate clearly when he or she needs the medication and Domiciliary care staff must never be expected to make a decision as to when it should be administered. Domiciliary care staff must only give as and when required medication if they are sure of the date and time of the last dose given to ensure the minimum interval between doses is adhered to and that the dose to be given shall not cause the maximum dose to be exceeded within a 24 hour period. When 12

administered the medication must be recorded on the Medicines Administration Recording Sheet, clearing stating the date, exact time of administration and dosage. 2.11 Special Storage Arrangements Where a special storage arrangement is required, this will be written on the DC1 and in the care plan. If there is a key it must be returned to the specified place when finished. Domiciliary Care Workers must never remove the front cover of the MDS to make it fit into a locked box and if this has already been removed this must be reported to the Domiciliary Care Supervisor. 2.12 Medication Errors Domiciliary Care Workers must report errors immediately to their Domiciliary Care Supervisor so that appropriate action can be taken to lessen the effects of the error. The Supervisor must immediately seek advice from the GP/ Pharmacist or GP Out of Hours Service if outside normal working hours and inform the Key Worker as soon as possible. In an emergency a 999 call should be made. The Domiciliary Care Worker must remain with the service user until they are informed they are allowed to leave by the Domiciliary Care Supervisor. All errors must be recorded on Datix and investigated by the Domiciliary Care Supervisor to identify any training or competency issues and determine the cause(s) of the error and an Action Plan completed and agreed with the worker/s concerned. A culture that allows staff to report incidents must be encouraged. Recording Trust Domiciliary Care Workers All errors and near misses must be recorded on the Trust Datix system by the Trust Domiciliary Care Supervisor according to Trust policy and RQIA notified if appropriate under RQIA reporting requirements. Recording - Independent Domiciliary Care Agency All errors and near misses must be reported to the key worker / commissioner as soon as possible (and no later than the next working day), who must ensure it is recorded on the Trust Datix system and record as a contract compliance according to Trust policy. These will be investigated by the key worker /commissioner or community nurse. A log of all errors should be maintained and RQIA notified if/ when appropriate under RQIA reporting requirements 2.13 Allergies to Prescribed Medication Where a DCW suspects; or a service user tells them they are having an allergic reaction to a prescribed medication, the DCW must report this immediately to the Domiciliary Care Supervisor. The Domiciliary Care Supervisor must seek advice from the GP/ Pharmacist or GP Out of Hours Service if outside normal working hours inform the Key Worker and the family. In an emergency a 999 call should be made. 2.14 Disposal of Unwanted Medicines Domiciliary care staff must not dispose of more than the dose of medicines for one administration time for example morning medicines. One dose may be disposed of by flushing down the service user s toilet. If domiciliary care staff are concerned regarding the amount of medicines in the service user s home this must be reported to the Domiciliary Care Supervisor for onward reporting to the Key Worker. This must be recorded in the care plan. It is the family member/ carer/ significant other s responsibility to return excess medications are returned to the pharmacy. Where there is no family member/ carer/ significant other and the medication is delivered by the pharmacy; they may also collect excess medication for disposal. 13

If support with medication is commissioned and there is no medication in the service users home for the Domiciliary Care Worker to give, this must be reported to Domiciliary Care Supervisor. 2.15 Medicines for Later It is generally acceptable for care workers to put out medication for people to take themselves at a later time. This should be done when it enables their independence not just for the convenience of the agency staff to avoid another visit (Care Quality Commission guidance, 2008) Medicines can only be left for a service user to take later when the service user is receiving level 2 assistance. 2.16 Service Users Refusing Service users must never be coerced to take medication. After encouragement if a service user refuses their medication the Domiciliary Care Worker must contact the Trust Domiciliary Care Supervisor for advice and record refusal in the comment section of the Medicines Administration Recording Sheet. Medicines should be disposed of as per section 2.14. 2.17 Complex Medicines Regimes The Trust definition of a complex medicine regime is: Medication from a Monitored Dosage System plus more than three* medicines from the original container at any administration time. or More than three* medicines from the original container at any administration time. *The following items must be recorded on the MIS in order for DCWS to administer them; however they do not have to be included in the total number of medicines out of the original container at any administration time: - Nutritional supplements e.g. Procal, Fortisip etc - Thickeners e.g. Nutilis - Medicated body washes e.g Balneum bath oil - Barrier creams e.g Conotrane - Emolients e.g. E45 Additional factors need to be considered when determining complexity, for example the number of liquid medicines and the stages and complexity in preparation of the medicines. Each scenario requires individual assessment and there may be occasions when it is agreed that Domiciliary Care Workers can assist with medications above this defined level for example if the medicines are low risk. Where the medicines regime is complex, the community nurse will liaise with the community pharmacist/ practice based pharmacist/ Managing Your Medicines Scheme/ Medicines Use Review/ the family / the GP/ domiciliary care/ community nursing with regard to seeking possible solutions to reduce complexity. 2.18 Controlled Drugs Where a Controlled Drug is being administered out of the original container two Domiciliary Care Workers where possible should witness the preparation and administration of the Controlled Drug and both should sign the Medication Administration Recording Sheet. A balance of the controlled drug should be kept using the Controlled Drug Balance Record (Appendix 5). 2.19 Thickeners Domiciliary Care Staff can only assist service users with thickened fluids where there are clear instructions in the care plan and they have attended an awareness session. 14

Domiciliary Care staff must record on the tin, the date the thickener was opened as they have a limited shelf life once opened. Domiciliary Care staff should ensure thickeners are put away safely. Thickeners should be recorded on the Medication Instruction Sheet with the following directions As per Speech and Language guidance. 2.20 Where two Domiciliary Care Agencies are involved with medicines administration Where two domiciliary care agencies have responsibility for administration of medicines the Community Nurse will issue a single medication folder in the service user s home containing a MIS to direct both agencies and a supply of Medication Administration Recording Sheets. The Trust will retain the completed Medication Administration Recording Sheets and provide a copy where requested by the agency (for internal investigation) within 72 hours. See Appendix 6 Flow Chart where (following assessment) Trust Domiciliary Care and a private domiciliary care agency are assisting a service user with their prescribed medications at level 3 15

3.0 Specific Medicines Procedures 3.1 Background This section outlines how domiciliary care staff can support service users with specific medicines procedures following training and assessment of competency. Where it is identified that a specific medicines procedure is to be commissioned via domiciliary care staff; the Domiciliary Care Workers involved must be trained and deemed competent in the specific procedure. Documentation It is the responsibility of the Community Nurse to ensure that the Medication Instruction Sheet is completed for specific medicines techniques performed by domiciliary care staff and the individualised procedural guidance is inserted into the care plan in the service user s home. Procedure guidelines for the most common specific medicines techniques are located on the Trust Intranet Clinical Guidelines Repository Site by typing in a key word www.southernguidelines.hscni.net. Training/Competency Training/competency for the following specific medicines procedures is covered in the MMSAs: Application of prescribed patches Application of prescribed creams, ointments and lotions Administration of prescribed eye drops For other specific procedures the Community Nurse or other qualified appropriate Health Care Professional provides the training. Competency assessment tools for the most common specific procedures are available on the Trust Intranet as outlined above. Competency for the administration of specific medicines procedures is transferrable. Once competency is achieved in the specific medicines technique the Domiciliary Care Worker is permitted to administer the medicines/s to other service users as directed in the care plan. This excludes client specific training. However there is one exception to this; in the instance of application of a Controlled Drug patch being delegated to Domiciliary Care Workers, a Community Nurse must go through a checklist for the individual service user with the workers involved as part of the governance arrangements (Appendix 7). It is the responsibility of the Domiciliary Care Supervisor to ensure that they have appropriate records of the training and competency assessments for domiciliary care staff who are performing specific medicines procedures as part of their duties and that competency is reviewed yearly. 3.2 Specific Medicines Procedures Specific medicines procedures, which a Domiciliary Carer can perform, are as follows: i Assisting a client with an oxygen mask or nasal specs and ensuring tubing is not kinked. NB this does not include adjusting the prescribed flow rate of oxygen unless it is specifically documented in the care plan and staff have been trained 16

by the COPD team to adjust the flow rate (the training is patient specific). The service user is monitored by the COPD team on a regular basis. ii iii iv v vi vii viii ix x xi Application of prescribed creams, ointments and lotions Measuring up liquid medicines in an oral syringe Giving prescribed medication via a nebuliser. Administration of prescribed eye drops. Application of prescribed patches Application of prescribed ear drops Application of prescribed nasal spray Application of prescribed nasal drops Assistance with using a prescribed inhaler Rescue medication such as Epipen or Buccal Midazolam in an emergency when the Domiciliary Care Worker has had service user specific training by an appropriate qualified Health Care Professional and signed onto to service user s care plan 3.3 Specific Medicines Procedures, which Domiciliary Care Workers are not permitted to Perform. i ii iii iv v vi Administer suppositories, enemas, pessaries or apply vaginal cream Administer injections, including insulin (or be involved in preparation of insulin injection). Exception of Epipen in emergency when trained specifically for that service user Administer medication via a naso-gastric tube Changing the oxygen cylinder or adjusting the oxygen flow rate except in circumstances outlined in section 3.2 Administer medication via a peg tube Administer medication via a bladder catheter The above lists are not exhaustive and staff may identify other tasks. A Domiciliary Care Worker should always seek advice if they have any concerns regarding specific medicines procedures. 3.4 Procedure for Domiciliary Care Workers (DCW) applying creams/ ointments/ lotions/ spray Domiciliary Care staff can apply a perfumed body lotion as part of personal care. Where a service user or their family/carer request assistance with a medicated cream, ointment or lotion that has been purchased over the counter the Over the Counter Creams procedure should be followed (Appendix 8). Please note all prescribed creams/ ointments/ lotions must be recorded on the Medication Instruction Sheet. 17

References Care Quality Commission, 2008 Pharmacy Tip: medication in a domiciliary care setting. http://www.cqc.org.uk/guidanceforprofessionals/socialcare/careproviders/guidance.cf accessed 28/07/2009 National Institute for Health and Clinical Excellence 2009, Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence NICE: London Regulation and Quality improvement Authority, 2009 Guidelines for the Control and Administration of Medicines; Domiciliary Care Agencies. RQIA: Belfast Regulation and Quality improvement Authority, 2012 Guidance on mandatory training for providers of care in regulated services RQIA: Belfast 18

19 Appendices

Name Address Postcode DOB Name of Carer/NOK Telephone No Referred by Reason for Referral Date of assessment Any known allergies Appendix 1 MEDICINES MANAGEMENT ASSESSMENT TOOL Tel No H&C No Tel No PART A Domain 4 of NISAT Tool can be completed as an alternative to Part A of this Tool Part A: to be completed by key worker in conjunction with service user and family / carer Please tick difficulty with managing medications Difficulty collecting medications from the pharmacy Forgetting to take medications / getting mixed up when to take which tablets Difficulty reading labels on bottles / containers Difficulty opening medication containers / bottles due to dexterity problems Difficulty removing tablets / capsules from foil or blister pack due to dexterity problems Service user has excess medicines in the home Service unsure of how to dispose of medicines no longer in use Service user unable to manipulate bottle / container and wishes to leave out medication to take later e.g. sleeping tablets Assistance from family/others Please state what assistance family / carers can give with medications 20

Possible interventions to resolve difficulty with managing medicines Problem Possible solution Possible contacts or referrals Unable to collect medications KW to support service user to link with Family / friend from pharmacy family member / friend re collection or check if home delivery service available Community pharmacist Forgetting to take medicines Getting mixed up when to take them Reminder telephone calls (? link in with voluntary sector schemes), SMS messages Telecare Reminder cards with list of medicines and dosing schedule Unsealed compliance aid filled by family / carer Voluntary organisations e.g. Good Morning Newry Community pharmacist Family /carer (DCWs not allowed to assist out of family filled aids) Community Pharmacist Monitored Dosage System Filled by pharmacist Difficulty reading labels Larger print on labels Community pharmacist Difficulty opening bottle Wing-tops / ordinary caps on bottles Community pharmacist /containers due to dexterity Larger bottles Difficulty removing pills from foil or blister packs due to dexterity Excess medicines in the home Unsure of how to dispose of medicines no longer in use Level 2 assistance from Domiciliary care worker Device for removing pills from foil or blister packs could be purchased Level2 assistance from Domiciliary care worker Medicines review by GP Clear out of medicines no longer in use Advice re storage / disposal Clear out of medicines no longer in use Referral to Domiciliary care service (only where all other avenues have been explored) Community pharmacist Referral to Domiciliary care service (only where all other avenues have been explored) GP Community Pharmacist Community Pharmacist OUTCOME OF ASSESSMENT Level 1 Service user can manage own medication from original containers or MDS Other Level 2 Service user can maintain control of his / her medications but requires assistance of Domiciliary care Worker (DCW) to open bottle / container or pop tablets / capsules out of blister pack Level 2 Medication Care Plan completed by Key Worker Referral to Community Nurse for Part B State what options have been explored before referring to community nurse Please note, where there is insufficient evidence that all avenues have been explored, PART A will be returned to the KW. Name Part A of assessment / Domain 4 of NISAT Tool completed by Job Title 21

PART B Following completion of Part A or completion of Domain 4 of NISAT Tool where a more detailed assessment is required Part B to be completed by community Nurse (CN) in conjunction with service user and family/carer Please tick difficulty with managing medications Service user confused / no understanding of what medications to take or when to take them Service user unable to actually lift tablets and put in mouth Service user non-compliant with medications History of taking medications incorrectly Side effects of medications putting service user off taking them Difficulty swallowing tablets Difficulty measuring liquid medicines Medications required to be administered covertly (as agreed by MDT) Possible interventions to resolve difficulty with managing medicines Problem Possible solution Possible contacts or referrals Service user non-compliant with medications Counselling Involving service user in decision making Referral to practice nurse for specific GP Community Pharmacist Practice nurse disease review e.g. respiratory review Side effects putting service user off Review of medication regime GP taking tablets Difficulty swallowing tablets Change of formulation of medicines GP SALT assessment Difficulty measuring liquid medicines Change of formulation of medicines GP Monitored Dosage Systems (MDS) (please circle as appropriate) Are medications currently in an MDS? Yes No If medications in MDS, is it a sealed MDS filled by a pharmacist? Yes No Where medications are in an MDS are their additional medications Yes No for example liquid medicines, sachets or tablets capsules that cannot be placed in an MDS? If yes to the above please list additional medications Before delegation to domiciliary care service if medicines are in an MDS this must be one that is filled by a pharmacist and sealed 22

Specific Medicines Techniques Is the service user prescribed creams/ointments/lotions, inhalers, nebuliser, medicated patch, eye ear drops or nose drops, oxygen If prescribed any of the above does the service user have any difficult managing these? Please state difficulty: (please circle) Yes No Yes No Before delegating to domiciliary care service, care plan for specific technique must be individualised and placed in home care plan and any onsite training / competency provided Possible interventions to resolve difficulty with managing specific medicines technique Problem Possible solution Possible contacts or referrals Can t use inhaler device Demonstrate inhaler technique (use Community Pharmacist placebo inhaler) Use adherence aid like e.g. GP Practice nurse Haleraid or suggest spacer, Turbohaler or breath actuated inhaler Can t apply cream Suggest adaptors or aids e.g. tube key to squeeze out cream Community Pharmacist Can t apply eye drops Auto-dropper for eye drops Community Pharmacist Complexity of medicines regime Is medicines regime complex as per Trust definition of complex regime? (Medicines out of MDS plus / or 3 other preparations at any of the administration periods or other complexities e.g. liquids using a syringe) Other complexity (please circle) Yes No Yes No Before delegating to domiciliary care service if medicines regime is complex CN must liaise with GP re simplifying regime and /or family /carer to explore other options to reduce complexity Only one liquid medicine requiring to be measured in an oral syringe can be delegated to Domiciliary Care Service 23

Possible interventions to resolve complex medicines regimes Complexity Possible solution Possible contacts or referrals More than 3 preparations outside of MDS at an administration time Review medication regime Arrangement with family to assist at administration times when more GP Family / carer More than one liquid medication to be measured in oral syringe Medication with variable dose for example warfarin complex Could service user manage tablets / capsules? Review medication regime Arrangement with family to assist at administration times when more than one medicine requiring to be measured in a syringe If INRs stable can Warfarin go into MDS?- ensure communication between KW and GP for future dose change Family / carer administer warfarin GP Family / carer Community Pharmacist Family / carer OUTCOME OF ASSESSMENT Level 3 DCW administers prescribed medications from MDS Original Container (as per Medication Instruction Sheet) Medicines from MDS plus original container (as per Medication Instruction Sheet) Assistance with specific medicines technique /s (as per Medication Instruction Sheet and individualised care plan for specific technique) Specify technique/s (Please tick) Documentation completed Medication Instruction Sheet Care plan for specific technique individualised Community Pharmacist informed Service User is being assisted with medications by Domiciliary care (Please tick) Assessment completed by Job Title Review Date 24

No KW ascertain if family / carer can assist SU with medicines Yes No further intervention necessary Appendix 2: Decision Tree: Supporting People with Medicines When need with managing medicines highlighted to KW KW completes Part A of Medications Assessment Tool or Domain 4 of NISAT Tool No Following completion of Part A of Assessment Tool or Domain 4 of NISAT Tool by KW if a more detailed assessment required CN completes Part B of Medication Assessment tool Where outcome of assessment indicates SU needs DCW to administer medication CN checks if medicines regime complex*? KW ascertain if any interventions that would enable SU to self-manage or enable family / carer to assist Yes No KW determine if SU can maintain control of medicines with minimal assistance from DCW Yes No Yes CN Liaise with GP re simplifying regime Liaise with family?cn involvement in administration Refer for intervention: Range of interventions depending on assessed need: Large labelling Easy opening containers Medicines reminder card MAR MDS Text/phone reminder Delivery service by pharmacy Level 1 SU manages own medication from original packets or MDS SU maintains control of medicines with: Assistance from DCW to open bottle / container Assistance from DCW to pop tablets / capsules out of a blister pack NB: DCW must request that the SU selects the medication bottle / container and must not direct the SU which medication to take Level 2 SU maintains control of medicines; DCW assists as specified by KW in level 2 Medication Care Plan DCW record assistance given on each occasion in care plan Are special storage arrangements required? No Yes (liaise with family) Level 3 DCW administers medications out of MDS, original container or both as per instructions in Medication Instruction Sheet (completed by CN) DCW records medication administered in Medication Recording Sheet. Where specific medicines techniques to be carried out CN inserts individualised procedure into care plan CN informs community pharmacist DCW assisting SU with medicines SU Service User MDS Monitored Dosage System *Complex Medicine MDS plus / or more than 3 medicines out of original container at any administration time MAR Medicines Administration Record DCW Domiciliary Care Worker KW- Key worker CN Nurse working in the community across all directorates 25

Appendix 3: Level 2 Medication Care Plan To be completed by the key worker following completion of Part A of the Medication Assessment Tool or Domain 4 of the NISAT Tool where the outcome of the assessment is that the Service User can retain responsibility for their medicines with minimum assistance from a DCW Name of Service User Address DOB H&C No Assistance to be given by Domiciliary Care Worker (tick as appropriate) Opening a medication bottle / container (at the request of the service user You must request that the service user selects the medication bottle / container You must NOT direct the service user which medication or how much to take Popping tablets or capsules out of a blister pack (at the request of the service user) You must request that the service user selects the medication You must NOT direct the service user which medication or how much to take If the service user requests more assistance than this or you have any concerns contact your Domiciliary Care Supervisor / Line Manager Signature of key worker Job Title Date Review Date 26

Arrangements when domiciliary care workers are requested to assist with prescribed oral medication, eye drops/ eye ointment and creams outside normal working hours The vast majority of service users will be able to self-administer additional prescribed medication outside of normal working hours or will have a family member/care who can assist until this medication is written in the Medication Instruction Sheet (MIS). The following guidance is for situations when a service user is unable to self-administer and has no family member/carer to assist Domiciliary Care Worker (DCW) contacts Domiciliary Care Supervisor (DCS) or OOH Shift Manager when requested to assist with newly prescribed medication that is not on the MIS If this is outside of normal working hours DCS/Shift Manager check if there is family member/carer who can administer this until it can be written up in the MIS Where there is no family member/carer who can administer this medication, DCS/Shift Manager ask DCW to check the label on the prescribed medication to ensure it is for the correct person, the date it was dispensed, how often it is to be administered and any special instructions Where the DCS has any concerns regarding the medication the Out of ours GP Service can be contacted or the dispensing pharmacy if appropriate Where it is an eye drop/eye ointment or cream, DCS/Shift Manager contact the Out of ours GP service to check if it needs to be commenced urgently. Where the Out of ours GP service advises that the eye drop or cream needs to commenced urgently, DCS/Shift Manager advise DCW to follow Standardised Guidance for eye drops/ cream until the procedure is inserted into the care plan. DCS/Shift Manager liaises with all DCWs who will be visiting service user to ensure they are informed of the additional medication and when it is to be administered. It is not the responsibility of DCW s to be inform other DCW s. An additional visit may be required to ensure the service user gets the medication at all administration times and at the prescribed intervals DCS/Shift Manager documents action taken DCW documents instructions given by DCS in service user s care plan DCS/Shift Manager contacts Key worker at the start of the next working day to request this medication to be written up in Medication Instruction Sheet 27 By the end of the next working day medication to be recorded on the MIS if not to be escalated to Locality manager

Appendix 5 Controlled Drug balance sheet Name of service user HCN Name of Medication Strength Please record balance at every administration Date and time No of tablets/ amount of liquid administered No of tablets/ amount of liquid that should be left Actual no of tablets left (if liquid leave blank) DCW signature DCW signature Please report if the medication is finished before it should be or there is medication remaining when it should be finished 28

Appendix 6 FLOW CHART WHERE (FOLLOWING ASSESSMENT) TRUST DOMICILIARY CARE AND A PRIVATE DOMICILIARY CARE AGENCY ARE ASSISTING A SERVICE USER WITH THEIR PRESCRIBED MEDICATIONS AT LEVEL 3 The Community Nurse (CN) will issue a medication folder in the service user s home with the information sheet on the front The CN will ensure there is a Medication Instruction Sheet in the folder providing directions to the Domiciliary Care Workers (DCW) The CN will leave some Medication Administration Recording Sheets in the folder The Trust Domiciliary Care Supervisor (DCS) will ensure there are Medication Administration Recording Sheets in the medication folder Domiciliary Care Workers from both agencies will administer medication at level 3 following the directions on the Medication Instruction Sheet DCS from both agencies will record medication administered sequentially on the Medication Administration Recording Sheets Medication Administration Recording Sheets will be collected and stored by Trust DCS Where the Private agency require a copy of Medication Administration Recording Sheets for an internal investigation; the Key Worker will ensure these are copied and made available within 72 hours 29

MEDICATION FOLDER WHERE TRUST DOMICILIARY CARE AND A PRIVATE DOMICILIARY CARE AGENCY ARE ASSISTING A SERVICE USER WITH THEIR PRESCRIBED MEDICATIONS AT LEVEL 3 PLEASE READ AND FOLLOW THE INSTRUCTIONS ON THE MEDICATION INSTRUCTION SHEET AND ANY MEDICINES PROCEDURES IN THIS FOLDER PLEASE RECORD MEDICINES ADMINISTERED SEQUENTIALLY (AFTER THE PREVIOUS DOMICILIARY CARE WORKER) ON THE MEDICATION ADMINISTRATION RECORDING SHEETS AS PER THE FOLLOWING EXAMPLE: REPORT ANY ISSUES TO YOUR LINE MANAGER 30