NICE – managing medicines in adult social care Mindy Bhalla Pharmacist Specialist, Care Quality Commission Cherise Gyimah Care Homes Pharmacist, Croydon CCG and NICE Medicines and Prescribing Associate Melanie Weatherley Chair Lincolnshire Care Association

Overview Key recommendations on medicines policies, medicines reconciliation, self–administration and audit A summary of the regulations An overview of the newly published quality standard medicines management for people receiving social care in the community (QS171) – What is medicines support? Assessing and recording medicines support How providers can support self-care in social care.

NICE guidance Managing medicines in care homes. Social Care guideline [SC1] Published March 2014 Managing medicines for adults receiving social care in the community. NICE guideline [NG67] Published March 2017 Medicines management for people receiving social care in the community. Quality standard [QS171] Published July 2018 Social care guidelines aim to improve outcomes for people who use social care support by ensuring that social care services and interventions are effective and cost-efficient. They do this by making recommendations about best practice, drawn from current evidence-based research. A multidisciplinary Committee comprising health and social care practitioners and lay members developed these guidelines.

Health and social care act 2008 Set out regulations for providers to meet CQC inspection to ensure providers are meeting regulated activities Some regulations include fundamental standards; the standards below which care must never fall Guidance on meeting the regulated activities is provided on the CQC website. http://www.legislation.gov.uk/uksi/2014/2936/contents/made

Medicines management Person Centered Efficient Safe Effective

Managing medicines in care homes People living in care homes have the same rights in relation to NHS care as the rest of us, as set out in the NHS Constitution. Care homes residents should have the opportunity to make informed decisions about their care and treatment. Person-centred care is important. Helping residents to look after and take their own medicines helps them retain their independence. When a person moves into a care home, staff should assume they can manage their own medicines, unless indicated otherwise. Each resident should have an individual risk assessment to determine the support they need to manage their own medicines. Care home providers should have a medicines policy which includes written processes for the safe and effective use of medicines.

Managing medicines for adults receiving social care in the community People have the right to be involved in discussions and make informed decisions about their care Person-centred care is important. Helping people to look after and take their own medicines helps them retain their independence. Each person should have an individual risk assessment to determine the support they need to manage their own medicines. Health and social care commissioners and providers should review their local governance arrangements to ensure that it is clear who is accountable and responsible for providing medicines support. When social care providers have responsibilities for medicines support, they should have a documented medicines policy based on current legislation and best available evidence. 

Medicines policies SC1 NG67 Sharing information about a resident's medicines Ensuring that records are accurate and up to date Identifying, reporting and reviewing medicines-related problems Keeping residents safe Accurately listing a resident's medicines Medication review Ordering medicines Self-administration Care home staff administering medicines to residents, including staff training and competence requirements Covert administration Homely remedies Assessing and reviewing a person’s support needs Supporting people to take their medicines Working with other health and social care providers Sharing information about a person’s medicines Keeping accurate and up to date records Managing concerns about medicines including safeguarding incidents Giving medicines to people without their knowledge (covert administration) Ordering and supplying medicines Transporting, storing and disposing of medicines Training staff and assessing their competency Cherise: So what does NICE say? NICE recommends that providers must have an up to date written medicines policy based on current legislation and best available evidence. Policy should include a written processes for various aspects of managing medicines , outlined are the areas that should be covered for each setting. Did you know that NICE has a baseline assessment tool for each of these guidelines? The tool can be used to evaluate whether your practice is in line with the recommendations in guidelines. It can also help to plan activity to meet the recommendations. NICE has also published a ‘checklist’ to help you put a local policy in place The next slides shows you how to access these tools Mindy: How do CQC look at this on inspection? Is there a medicines policy? Does it reflect current guidance e.g. NICE guidance? Have staff signed to say they have read it and can they access the policy when needed? Does it reflect practice? Looking to see if the policy is suitable for that individual service. Should be appropriate length and detail for staff to be informed but also to understand and be able to practically implement the information Melanie: what does this mean practically for CH managers? It is important that homes have a policy and procedure that they can understand. Consistency across an area system can be helpful, particularly when looking at interaction with other parts of the system. Reflection: Does your organisational policies adhere to NICE guidance? Are the CQC fundamental standards being met? Consider what is working well. Are there any areas of concern?

This slide shows how you can access the tools and resources associated with SC1. Managing medicines in care homes.

Medicines reconciliation SC1 The care home manager or person responsible for a resident's transfer into a care home should coordinate the accurate listing of all the resident's medicines as part of a full needs assessment and care plan and consider the resources needed for this to occur in a timely manner. (see recommendation 1.7.1) NG67 When social care providers have responsibilities for medicines support, they should have robust processes for communicating and sharing information about a person's medicines that take account of the person's expectations for confidentiality. (see recommendation 1.4.1) NG67 Social care providers with responsibilities for medicines support should have robust processes for handling changes to a person's medicines received verbally from a prescriber. (see recommendation 1.4.6) Cherise: What does NICE say? There needs to be a robust process for ensuring that you have an up to date , accurate list of the person’s medicines, this is particularly important following transfers of care. Process should cover recording information: in the person’s care plan and medicines administration record from correspondence and messages about medicines in transfer of care letters (medicines summaries) of prescription copies or medicines ordered Medicines reconciliation should involve the person and/or their family members/carer, a pharmacist, other health and social care practitioners involved in managing medicines for the resident Recommendation 1.2 of NICE guidance on medicines optimisation (NG5) outlines the specific information that should be available for process on the day a person moves from one care setting to another Mindy: How do CQC look at this on inspection? How do staff check what medicines people are taking when they arrive at the service? What information sources are used – Person and/or family, GP, hospital discharge, community pharmacy, community or other specialist nurse How do staff liaise with other healthcare professionals to ensure that people’s medicines are reviewed in a timely manner? Are records kept of requests for GP review? Could the person contact a healthcare professional for advice or support? See FAQ Medicines reconciliation and review How do staff ensure medicines remain available to people when they move between care settings? How is information about medicines transferred? Services should have processes in place for sharing, accurate information about a resident's medicines, including what is recorded and transferred when a resident moves from one care setting to another. The care home manager or the person responsible for a person's transfer into a care home should coordinate the medicines reconciliation as part of a full needs assessment and care plan. They should ensure that a designated health professional has overall organisational responsibility for the medicines reconciliation process. The process should be determined locally and include: organisational responsibilities responsibilities of health and social care practitioners involved in the process (including who they are accountable to) individual training and competency needs resources needed to ensure that medicines reconciliation occurs in a timely manner   There needs to be a regular review and monitoring of the effectiveness of these processes. Melanie: what does this mean practically for CH managers? We found the topic of reconciliation one of the more challenging areas when we were reviewing the procedures. It can be difficult to engage with GPs and hospitals to make sure that medication is correct. This is something can be helped if we work together as a system.

Self administration SC1 Care home staff should assume that a resident can take and look after their medicines themselves (self-administer) unless a risk assessment has indicated otherwise. (see recommendation 1.13.1) NG67 Do NOT take responsibility for managing a person's medicines unless assessment indicates the need, and has been agreed as part of local governance arrangements. (see recommendation 1.13.1) It is important for people living in care homes to maintain their independence, and that they can have as much involvement in taking their medicines as they want. Care home providers should ensure they have a policy in place and that their process for self-administration of medicines (including controlled drugs) includes individual risk assessments, an assessment to ensure the appropriate support is provided, storage of medicines and record keeping. Cherise: What does NICE say? Let’s discuss what needs to be considered when a resident wishes to look after and take (self- administer ) their own medicines Legislation (see recommendation 1.2) Residents should be supported to make informed decisions and these decisions should be recorded. NICE guideline (see recommendation 1.13.1) - Above Governance (see recommendation 1.1.2) Care home providers should have a care home medicines policy with a written processes for helping residents to look after and take their medicines themselves (self‑administration) Risk Assessment (see recommendation 1.13.2 and 1.13.3) - An individual risk assessment should be carried out to find out how much support a person needs to carry out self-administration resident choice if self‑administration will be a risk to the resident or to other residents if the resident can take the correct dose of their own medicines at the right time and in the right way (for example, do they have the mental capacity and manual dexterity for self-administration?) how often the assessment will need to be repeated based upon individual resident need how the medicines will be stored the responsibilities of the care home staff, which should be written in the resident's care plan. Recording (see recommendation 1.13.4 and 1.13.5) - Providers of adult care homes must ensure that records are made and kept when adult residents are supplied with medicines for taking themselves (self-administration), or when residents are reminded to take their medicines themselves. Storage (see recommendation 1.13.6) - Care home providers should ensure that medicines for self-administration are stored as identified in the resident's risk assessment (for example, in a lockable cupboard or drawer in a resident's room). Residents should be able to get any medicines that need special storage at a time when they need to take or use them Mindy: How do CQC look at this on inspection? CQC understands It is important for people living in care homes to maintain their independence, and that they can have as much involvement in taking their medicines as they want. Care home providers should ensure they have a policy in place and that their process for self-administration of medicines (including controlled drugs) includes: individual risk assessment obtaining or ordering medicines storing medicines Appropriate records e.g. receipt of medication, record of adherence reminding or prompting people to take their medicines monitoring adherence disposal of unwanted medicines The degree of self-medication can vary from person to person and for different medicines. As mentioned, care home staff should carry out an individual risk assessment to find out how much support a person needs to carry on taking and looking after their medicines themselves. Risk assessment should always fundamentally consider the persons choice. Assessments should also be reviewed at appropriate intervals to ensure they are still a reflection of current practice and needs. (for example, during an acute illness) The responsibilities of the care home staff, which should be written in the person’s care plan and should include an effective way of monitoring adherence The care home manager should coordinate the risk assessment and should help to determine who should be involved. This should be done individually for each person and should involve them (and their family members or carers if they so wish) and care home staff with the training and skills for assessment. Other health and social care practitioners (such as the GP and pharmacist) should be involved as appropriate to help identify whether their medicines could be adjusted to enable the person to self-administer. Support to self-administer Self-administration of medicines is not an ‘all or nothing’ situation. For example, some people might keep and use their own inhalers but not their other medicines. Support may include practical help such as providing a glass of water. Other support could include reminder charts, large print labels, easy to open containers, help measuring liquids, use of compliance aids, devices to help with inhalers or eye drops or colour coding of labels. Support may also be providing the person with suitable information about their medicine, including how to take it and any potential side effects. Storage Care home providers should ensure that medicines for self-administration are stored as identified in the person’s risk assessment (for example, in a lockable cupboard or drawer in their room which is not accessible by other people). People should be able to access any medicines that they need, when they need to take or use them. If a person in a residential setting is self-administering they can hold their own, individually dispensed, supply of Controlled Drugs in their own lockable cupboard. Record keeping Adult care home providers must ensure that records are made and kept when people are supplied with medicines (including controlled drugs) for self-administration or when people are reminded to take their medicines themselves. There is no need for staff to fill in the administration section of the MAR chart when people self-administer their medicines, but the chart should indicate that the person self-medicates and how adherence is effectively monitored. Melanie: what does this mean practically for CH managers? This is an area of concern for many managers. All of the guidance stresses the need to respect the right to self-management, but we don’t always follow that through. The Mental Capacity Act allows

Audit A key responsibility for organisations providing care was highlighted in The Royal Pharmaceutical Society’s report (2012): ensure systems and processes ‘focus on improving patient safety and patient outcomes’ and ‘consistently monitor and audit how effectively they transfer information about medicines’ Cherise: What does NICE say? Nothing specific Mindy: How do CQC look at this on inspection? Are any audits undertaken, MAR charts and others? Are action plans produced and followed up? The Royal Pharmaceutical Society’s report (2012) also provides 3 key responsibilities for organisations providing care. Organisations should:  ‘ensure that they have safe systems that define roles and responsibilities within the organisation, and ensure that health professionals are supported to transfer information about medicines accurately’  ensure systems and processes ‘focus on improving patient safety and patient outcomes’ and ‘consistently monitor and audit how effectively they transfer information about medicines’  share ‘good and poor practice in the transfer of medicines … to improve systems and encourage a safety culture’. Cant rely on audits to identify errors. They are a useful tool in highlighting areas that need improvement and also provide assurance that medicines are being managed appropriately and as per policy. Can have support externally for audits e.g. CCG audits, online national tools Melanie: what does this mean practically for CH managers? We often find that managers think that auditing is the same as checking everything. The concept of a sample with escalation when errors are identified was difficult for some providers to grasp. Monitoring by the individual and the person following them is the most important.

Self care People who receive social care should be supported to access over-the-counter (OTC) products to enable them to self-care, with the appropriate safeguards put in place. Access to OTC medicines to self-care is an issue of equality and providers should have policies in place to support people who wish to access OTC products in a timely manner. This is different to the use of homely remedies. Guidance for Clinical Commissioning Groups (CCGs) on conditions for which OTC medicines should not routinely be prescribed in primary care was published in March 2018. Providers need to liaise closely with clinicians to identify people who are affected and make appropriate arrangements. OTC and minor ailments SC1 Care home providers offering non-prescription medicines or other over-the counter-products (homely remedies) for treating minor ailments should consider having a homely remedies process . (see recommendation 1.16.1) If a person is living at home, they can choose whether to buy over-the-counter medicines (also known as homely remedies), for example paracetamol for pain relief. People retain that choice when they receive social care in the community and it is not usually appropriate for a care worker to influence the choice of over-the-counter medicines that the person wants to buy. However, problems may arise when a person asks a care worker to buy or administer an over-the-counter medicine. NG67 The Committee agreed that while a person receiving care may need support to select or choose an over-the-counter medicine the responsibility for its selection and the taking of the medicine remains with the person. NG67 The Committee concluded that the care provider should have robust processes in place for care workers on: when to seek advice from a health professional; ensuring that the person understands and accepts any risk associated with taking the medicine; what information needs to be recorded, for example, the name and quantity of the medicine. Mindy There should be a policy to support people who wish or need, to self–care. The policy should outline the necessary safeguards to support people to self care when carers or relatives provide OTC products. For example, how people who may lack mental capacity to make decisions are protected. It is good practice on admission to the care home or when a domiciliary service is commissioned to discuss health needs and medicines with the person and their family. This should also include the use of OTC products. There should be a clear care plan including how reviews will be triggered to ensure that medicines given are safe and still appropriate.

Medicines support The person’s medicines support needs should be identified and assessed as part of the overall assessment of their needs and preferences for care and treatment. People undertaking this assessment must have the necessary knowledge, skills and experience to do so. The person (and their family) should be involved in all stages of the process. Before any medicines support is provided by a social care provider, commissioning and contractual arrangements need to be discussed, agreed and recorded as part of the local care planning process. This is to ensure that it is clear who is responsible and accountable for the decisions being made, and which providers will deliver each aspect of medicines support. Cherise: Definition : The term 'medicines support' is defined as any support that enables a person to manage their medicines. This varies for different people depending on their specific needs. (NG67) Home care workers should only provide the medicines support that has been agreed and documented in the person’s care plan” This is a really important point – if it is not documented in the person’s care plan, the care worker should not be providing medicines support. Remember, this may only apply to certain medicines too. An example might include that a care worker is to administer all oral medicines, but an injectable medicine such as insulin, may instead be administered by a community nurse. Mindy: As part of our regulatory role and inspection, CQC will look to see evidence of the following: When a person is assessed for medicines support, the provider Engages with the person (and their family members or carers if this has been agreed with the person) about their support needs and preferences, including: social, cultural, emotional, religious and spiritual needs expectations for confidentiality expectation for advance care planning understanding of why they are taking their medicines what they are able to do what help they need (i.e. reading medicine labels, using inhalers or applying creams) Many people want to actively participate in their own care. Enabling and supporting people to manage their medicines is an essential part of this, with help from family members or carers if needed. The following points are also key for an accurate and meaningful assessment: How does the person currently manage their medicines? How do they order, store and take their medicines currently? Does the person have any problems taking their medicines (especially if taking multiple medicines) Are there nutritional and hydration needs? Who will be the person to contact about their medicines? This would ideally be the person in receipt of care, but they may choose this to be a family member, carer or care coordinator Time and resources likely to be needed to provide support Recording Where people need support, we expect to see a record of the following discussions in the medicines support care plan : how their needs and preferences will be met, including expectations for confidentiality and advance care planning how consent for decisions about medicines will be sought who to contact about their medicines what support is needed for each medicine and how this will be given who will be responsible for providing medicines support, particularly, when more than one care provider is involved “

QS171 Statement 1 Adults having an assessment for social care in the community have their medicines support needs included in the assessment. Statement 2 Adults receiving medicines support in the community from a social care provider have their general practice and supplying pharmacy informed that support has started. Statement 3 Adults receiving medicines support in the community from a social care provider have a record of the medicines support that they need in their care plan. Statement 4 Adults receiving medicines support in the community from a social care provider are given information on how to raise any medicines-related problems. Cherise: What does NICE say? Start with clarification that this is for home care - there are QS for care homes QS85 At this point we want to highlight the quality standard on medicines management for people receiving social care in the community QS171 which was published in July . It covers assessing whether people need help with their medicines and deciding what medicines support is needed to enable people to manage their medicines. It also includes communication between health and social care staff, to ensure people have the medicines support they need. It describes high-quality care in priority areas for improvement. Statement 1 People's medicines support needs should be assessed as part of an overall assessment of needs and preferences for social care in the community, and then as needed. This helps people and their families or carers to share their aims and goals for how they manage their medicines. It also allows them to agree any support needed from services to take medicines safely and effectively. Statement 2 Knowing who is responsible for providing medicines support and who to contact allows prescribers to communicate any changes to medicines to the relevant person. This helps to ensure that all services involved in medicines support can share information about any changes to medicines or medicines support needs, and that people receive the support they need to take their medicines safely and effectively. Statement 3 Medicines use can be complex, particularly when people have several long-term conditions and are taking multiple medicines. It is important that people taking and administering medicines have an accurate record of the medicines support needed. This includes information about what support is needed, how it should be provided and who can provide the support. This can help to make sure that medicines are taken safely and effectively and enables people to manage their medicines. Statement 4 People receiving medicines support, and their families or carers, need to be able to raise any concerns about their medicines and the support needed to take them. This can help people to have their concerns addressed, improve management of medicines and may prevent medicines-related incidents. It can also help services to learn from and prevent further medicines-related problems. Mindy: How do CQC look at this on inspection?

CQC resources CQC external website Select guidance for providers On left side of page under “see also” select Adult social care medicines FAQ’s

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