Purpose
To ensure medicines are handled safely, administered as prescribed and that people are supported to take an active role in decisions about their medicines.
Scope
All staff involved in any part of the medicines pathway, and all medicines including homely remedies and topical preparations.
The medicines pathway
Ordering and receipt are reconciled against the MAR chart; discrepancies are resolved before the cycle starts.
Storage is secure and temperature-monitored daily, with fridge readings recorded and out-of-range readings escalated.
Administration follows the six rights: right person, medicine, dose, route, time and documentation, with the MAR signed at the point of administration.
Refusals, omissions and 'as required' medicines are recorded with a reason and a review of effectiveness.
Controlled drugs
Stored in a controlled drugs cabinet compliant with the Misuse of Drugs (Safe Custody) Regulations, with two-person checks on administration and running balances verified weekly.
Covert administration and capacity
Covert administration is only used following a documented mental capacity assessment, a best-interests meeting including the prescriber and pharmacist, and a written covert administration plan reviewed at least monthly.
Medicines errors
Errors are reported immediately, clinical advice is sought, the person is monitored and the incident is recorded and analysed for system causes.
A no-blame reporting culture is maintained; concealment of an error is the disciplinary matter, not the error itself.
Training and competency
All staff receive induction training on this policy before working unsupervised, refreshed at least annually or sooner following incident learning or a change in guidance.
Competency is confirmed through observation of practice, supervision discussion and reflective questioning — not attendance records alone.
Training records are maintained centrally and gaps are reviewed monthly against the training matrix.
Governance, monitoring and accountability
The registered manager holds overall accountability for this policy. Day-to-day implementation is delegated to named leads recorded in the service's accountability matrix.
Compliance is monitored through the service audit calendar, with findings reported to the monthly governance review and escalated to the provider board where risk is rated high.
Every audit finding is converted into an entry on the improvement action tracker with a named owner, priority rating, target date and evidence of completion.
Learning is shared with the whole team through team meetings, supervision and reflective practice sessions. Where a theme recurs, the policy itself is reviewed rather than the individual blamed.
- Weekly medicines audit covering stock balance, MAR gaps, temperature logs and controlled drugs.
- Annual competency assessment for every staff member who administers medicines.
- Interruption-free administration: staff administering medicines are not allocated other tasks.
- Six-monthly medication review with GP or pharmacist, including STOPP/START and anticholinergic burden review.
- Immediate clinical escalation pathway for any suspected overdose, omission of a critical medicine or wrong-person administration.
- Duty of Candour applied to any error causing moderate harm or above.
- Thematic review of all errors quarterly with actions targeted at systems, staffing and layout.
- Information about medicines is provided in accessible formats and community languages so consent is genuinely informed.
- Extra safeguards apply to people who cannot report side effects verbally, including structured observation for pain and discomfort.
- Antipsychotic prescribing for people with dementia or a learning disability is monitored and challenged in line with STOMP principles.
Evidence of compliance
- Weekly medicines audits
- Competency assessments
- Error log and thematic analysis
- Covert administration plans
Suggested review cycle: Annually, or following a serious medicines incident.