At the time of writing this article on 30 April 2020, there have already been significant developments in the health and social care sector due to the coronavirus pandemic which has meant that guidance and best practice advice has changed rapidly in this area.
In this article, I will focus on the issue of medication management in care homes specifically and consider the key guidance that has been published.
Providers are required to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Regulation 12 states that “Care and treatment must be provided in a safe way for service users” and under Regulation 12(g) providers are responsible for “the proper and safe management of medicines”. Although these are unprecedented times for the health and social care sector, it is worth reminding providers that the duty to ensure that service users are kept safe from harm does not diminish.
CQC guidance on medication management during the Coronavirus pandemic
CQC has published various guidance on different medication management issues during the coronavirus outbreak. The guidance is regularly being updated by CQC and published on its website. I will consider some of the key guidance below:
- Handwritten Medicine Administration Records (MARs)
The NICE Social Care Guideline: ‘Managing Medicines in Care Homes’ (2014) sets out recommendations for good practice on the systems and processes for managing medicines in care homes. In particular, it considers prescribing, handling and administering medicines. With regards to MARs, NICE states that they should be legible and include the following:
- the full name, date of birth, and any known allergies
- details of any medicines the resident is taking, including the name of the medicine and its strength, form, dose, how often it is given and where it is given (route of administration)
- any special instructions about how the medicine should be taken (such as before, with or after food)
Providers have a duty to maintain accurate and up-to-date records about medicines for each person receiving medicines support. In relation to MARs, CQC states that, new handwritten MARs should only be produced in exceptional circumstances by a member of care home staff with the necessary skills and competence for managing medicines. The new record should also be checked for accuracy and signed by a second trained and skilled member of staff before it is first used.
The charity ‘Skills for Care’ recently issued guidance in relation to staff training during the COVID-19 outbreak and stated that medication management training and refresher training was one of the areas that remains relevant at this time.
- Inappropriate use of sedative medicines to enforce social distancing guidelines
CQC acknowledges that deciding how to manage vulnerable people who may not understand social distancing guidelines remains a challenge. Many service users do not have the mental capacity to understand and follow these guidelines which could place them at increased risk of contracting and spreading coronavirus.
CQC states that in these instances providers must act in a way that is proportionate, pragmatic, safe, and focused on the best interests of individuals and the wider system. CQC provides an example of providers considering extra measures to protect service users who lack capacity by depriving them of their liberty i.e locking people in their own rooms, using medicines to sedate them or stopping them from meeting others.
CQC refers to S4.5 of its Key Lines of Enquiry for Adult Social Care, ‘How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?’ CQC states that “We do not advocate the use of sedative medicines or physical restraint to deprive people of their liberty. Instead, we encourage providers to look at alternative methods to minimise the need for any form of restraint. Any decisions should be carefully considered by a multidisciplinary team and documented appropriately.”
CQC does not discuss what the ‘alternative methods’ might be and instead refers providers to the Department for Health and Social Care (“DHSC”) guidance, ‘The Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) During the Coronavirus (COVID-19) Pandemic’ published on 9 April 2020.
- Delegating medicines administration
CQC states that care workers who support people with medicines administration must be appropriately trained and competent to carry out this task.
Some medicines, for example insulin injections, cannot be routinely administered by a care worker. However, a Registered Nurse (“RN”) can delegate the administration of these medicines to a care worker in circumstances where the RN is confident that the care worker is competent to take on the task and if the delegation is in the best interest of the person receiving medication.
It is important that staff have had extra training and competency checks before undertaking these tasks. Providers should also consider how to obtain consent and there must be robust person-centred care plans in place, which support carers to identify when to escalate concerns about a person’s care.
- Medicines awaiting return to community pharmacy
CQC acknowledge that due to capacity and infection control measures, some community pharmacies are not accepting medicines returns. CQC state that if this situation arises, the medicines should be stored securely with access restricted to authorised staff and care homes should update their risk assessments to reflect this.
- Controlled drugs as stock in care homes
With regards to care homes keeping anticipatory medicines for end of life care in stock, CQC state that such a decision needs to be balanced with the impact of increased demand on the medicines supply chain. NHS England advise that care homes should not routinely hold anticipatory medicines stock and that supplies should be centralised as much as possible.
- The re-use of medicines in care homes
The Human Medicines Regulations 2012 provide that Prescription-only medicines (“POMs”) must only be supplied on prescription to a named person. Once prescribed, the medicines become the property of that named person and must not be supplied to anyone else. However, due to the unprecedented impact of COVID-19, DHSC and NHS England and NHS Improvement have recommended a relaxation of previous recommendations and the NICE guideline to accommodate re-use of medicines, under very specific circumstances and only in a crisis situation.
These recommendations are set out in the DHSC guidance ‘Coronavirus (COVID-19): reuse of medicines in a care home or hospice’. The guidance provides advice in relation to using medicines labelled for one patient who no longer needs them for another patient and considers circumstances when a medicine is suitable for re-use.
Due to coronavirus pressures, CQC acknowledge that providers might need to re-use medicines to ensure that service users receive timely access to essential prescribed medicines. CQC state that providers should act in a way that is pragmatic, safe and which focuses on the best interests of service users and the wider system.
The Covid-19 crisis and beyond
Whilst it is a very challenging time for the sector, providers’ regulatory duties in relation to medication management do not go away.
If providers implement the various medication management guidance issued by CQC, the DHSC and other bodies to help cope during the pandemic, my advice is to have detailed risk assessments in place which reference the specific guidance that has been relied on when assessing risk and making decisions.
CQC has currently suspended its routine inspections but when they are resumed, whilst we hope that CQC will be proportionate and consider Regulation 12 in context of the coronavirus pandemic, this cannot be guaranteed and it is likely to depend on the approach of individual inspectors.
To help prevent CQC from taking enforcement action further down the line, providers should ensure that staff training is up to date and that all risks have been considered and documented appropriately!