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Teach care home residents to administer own drugs, says NICE

  • 8 Comments

Care home staff should place residents at the heart of decisions about their medication and support them to administer it themselves where possible, according to new draft quality standards from the National Institute for Health and Care Excellence

The guidance, which looks at medicine management in care homes and was put out to consultation today, said that self-administration was important for helping those living in care homes to be independent.

The document – called Managing Medicines in Care Homes – advises care home staff to carry out risk assessments to determine how much support each resident would need in administering their own medication. It highlights that a resident may be able to manage one type – such as oral tablets – but not others, such as eye drops.

Professor Gillian Leng, deputy chief executive and director of health and social care at NICE, said: “Children, young people and adults living in care homes often have complex health issues and can be more vulnerable than other people. Because of this, care homes may decide that decisions about medication are best made by staff. However, this may not necessarily be true.

“Evidence shows that involving people in decisions about their own care and supporting them to take an active role in managing their medicines can help them feel valued”

Gillian Leng

“Evidence shows that involving people in decisions about their own care and supporting them to take an active role in managing their medicines can help them feel valued and improve their quality of life,” she said.

In its guidance, NICE also provides advice on avoiding medication errors in care homes.

It said that GPs should provide a “clear written process” when prescribing medicines to care home residents.

The guidance pointed to a study from 2009 – called the Care Home Use of Medicines Study – which found more than a third of care home residents experienced at least one prescribing error, most commonly due to incomplete information on prescriptions.

Professor Gillian Leng

Professor Gillian Leng

NICE also emphasised the need for accurate medicine records on the day of transfer into a care home, and good communication between providers of health and social care as being key to avoiding medication errors when a patient was transferred.

At least one multidisciplinary medication review every year should take place for residents, the guidelines added, in order “to help to identify issues with medicines before they can cause harm”.

A public consultation on the draft quality standard will run until 7 November, with final guidance expected in March 2015.

  • 8 Comments

Readers' comments (8)

  • The problem with nursing is directly related to this issue. I'm going to address this issue in relation to the 'ordinary' nurse..no fancy specialisms.
    20-30 years ago the ordinary ward or nursing home based nurse faced probably faced less than half the sheer quantity of medications evident today thanks to a variety or reasons which would take a long paragraph of its own.
    At that time the registered nurse was constantly reminded that effective nursing was about managing the shift via effective delegation..it was NOT simply about completing tasks.
    With readily available enrolled nurses and many available students and pupil nurses (some..i.e. third years who were considered competent were able to take on many of the tasks or the regular staff nurse) and a drug round that took a third of the time that typically takes today the issue of administering medication was not a major one. Fast forward 25 years. Now the ordinary nurse, typically alone (certainly in nursing homes) must complete the task alone. This means that the closest she can get to managing her shift is to peer out from over the drug trolley and try and spot anything untoward..she mostly cannot participate in ordinary regular care..cannot teach whilst care occurs..cannot correct the basic or significant malpractices that inevitably occur from time to time..this all happens at the crucial periods..getting up, participating with breakfast..lunch..teatime..now increasingly 7pm medications as well. In respect of mental health and LD..coordinating proper effective feeding..proper independence promoting mobilising that cannot be best taught or overseen if not participated in. Her lot is to pot up..lock the trolley..close the MAR file..find the pt..give the med..return..reopen trolley and MAR file to the next pt whilst dealing with one consequence of person-centred-care..15 boxes of paracetamol..one of which is bound to run out...eventually finish by which time its over half way to lunch..check that all MAR sigs completed and then start counting all the tablets and documenting and investigating any irregularities as an example of best practice.
    Then she has to check that sufficient meds have been ordered so as not to run out whilst remembering to find the eye drops that she earlier delayed until she got a new one from the locked fridge at the end of the round and that she must remember to sign to avoid a disciplinary file note.
    Unlike years ago she cannot depend upon anyone else to help her e.g. by "running" the paracetamol to the patient because this is unacceptable practice.
    CDs now need not one double sig but often 3 as a CQC impressing example of good practice..the fact that mostly only one actually gives it due to minimal staffing and inherent trust makes abuse very possible even with 10 double signings..again unlike years ago even before MAR sheets arrived with 2 staff i.e. witnessing administrations. Similarly trolleys "shackled" to the wall with screw heads intact that could be removed with a dining knife within two minutes.
    Why?..It is now about "verisimilitude"..the lawyer placating appearance of truth. Thus shift management is left to unregistered "seniors" chosen for their strident and therefore independent and therefore often difficult to manage personalities unlike yesteryear when the enrolled nurse, trained for the role effectively functioned as a qualified nurse and stood in for the registered nurse according to how the registered nurse wanted to manage her particular shift.
    The result is that the ordinary nurse is regarded as increasingly irrelevant with unqualified staff knowing that medication is no big deal (given the identical task in "residential" services) but in "nursing services attended to by nurses who earn over twice as much but unlike yesteryear cannot delegate the task due the the services "nursing" status paradoxically that would enable her to actually both nurse and to manage the shift as it used to be.
    The consequential reality..more visiting "specialisms"..speech and language therapists who have effectively changed their role and stepped into what was once a clear nursing practice area and resentful, not helpful care assistant colleagues often unwilling to offer the smallest of assistance because they're "not qualified" and overworked over-stressed nurses who just want to hand over and go home.

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  • Common sense rather than scientific evidence suggests I would have thought that self-medication might actually make the problem of time spent on medication rounds and therefore the common shift management dilemma worse because she would now have to additionally oversee and patiently help the self-administrations of service users taking their own paracetamols which would significantly increase the already excessive task time on the typical med round even further..probably to lunch in the case of the morning round.
    Some nursing areas eg the elderly, LD and many MH conditions do not amount to medical "illnesses" as such but are necessarily incorporated into a medical model by 1) their legal care status 2) medical practitioners automatically triggering legal protection from the common allegation of "negligence"..and 3) maintaining central or near central roles in each "case".
    That often means prescribing of course ..without having to administer.
    Increasingly of course we now have non doctor prescribers all of whose activities still require the rigors of MAR sheet best practice even fortisip milkshakes.
    The kind of question that this issue inevitably brings about is..Is the successfully completed tasks of risk-assessed, planned and properly documented self-medicating more important than enabling the service user the extended practice or indeed re-skilling of for example eating their own meals, using the toilet independently again or mobilising again or for longer etc via the traditional applications of say active prompting, fading and effective social reinforcement or are these not considered to be the kind of practical objectives suitable for the modern graduate nurse?
    If self medication is considered more important or more suitable as an objective for the modern nurse already without time then to whom can it delegated, who has the responsibility for its implementation, application, review and indeed who has overall responsibility?
    If a service user has capacity but makes an error..is the nurse responsible for poor supervision? Similarly if the user palms the med will the nurse be held responsible again for poor supervision?

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  • Oh dear. Nice mostly get things right, but on this occasion they're way off the mark. I've worked in a few care homes in the past and can honestly say I could count on the fingers of one hand the number of residents that would be able to safely self administer their medications.

    With the best will in the world, even for those with the necessary dexterity to open bottles and packets where are the medicines to be stored, what happens if a service user takes the wrong tablet or dose who is accountable?

    Self administering medicines in hospitals is a different matter and I think there is huge scope there.

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  • I would agree with all the above - but especially that NICE really doesn't show that it knows the population of care homes these days. The residents in residential care homes are more dependent and with chronic complex conditions than the residents in nursing homes in the nineties. Residential care home staff are undertaking medicine rounds that are as complicated as nursing home medicine rounds. Also - some homes now have medication box stored in each care homes residents room and that would be ideal if residents were in their rooms - with more social activities encouraged and happening then residents are mostly in lounges. Obviously there are other reasons from residents not to be constantly in their own rooms. Lots of issues and NICE has not dealt with these. Maybe we ought to ask MY Home Life UK - which is now based in City University to do a systemic overview of advice and guidance come up with the best - consulting with care homes, pharmacies and GPs too.

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  • As a recent Care Home Registered Manager we always risk assessed whether residents were able to manage their own medication and whether it was safe for them to do so on admission. On some occasions residents came in to the home and we enabled them to manage their own meds, but after a short while it became very clear that it was unsafe for them to do so as they were at risk of over or under medicating. In these instances we negotiated what they could and couldn't safely do and took over responsibility only when it was clear that it would be necessary to protect them from their own drug errors. This was a residential home and as the only trained nurse ( but not able to function as one due to CQC registration conditions) most of the medication was dispensed by the carers after undertaking their medication administration training. We were audited on our practice by the community pharmacist and by internal audit procedures. The pressure on staff is great and disturbance at medication rounds was inevitable raising the risk of errors. The morning round is the heaviest and although one or two residents were on no medication, supporting the rest takes a great deal of time. In the dementia care home I previously managed this was even worse and as one commentator has already remarked takes until nearly lunchtime. It can be a very stressful task day in and day out, especially with the additional pressures of staffing and unpredictable incidents occurring during medication rounds. NICE in theory but try it in practice.

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  • Well I must say the first contributor got it absolutely SPOT ON!! Love it! and agree with what others have put on here too.BRAVO!

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  • I wholeheartedly agree with the first contributor! I have been a Registered Manager for 11 years in a Nursing Home followed by 4 years in a more senior managerial position and I have seen incredible changes in the amount of medication, long term conditions, required documentation and regulation of care homes. Nursing in Care Homes is no longer an 'easy option' or a 'second class' nursing as depicted by many but is a hugely rewarding, complex, autonomous nursing career with many rewards and the time for compassion and caring (between medicine rounds). NICE are not looking at the real world - of course we encourage independence but residents are not always fit enough to manage their medication safely - and who is accountable if they make a mistake - safeguarding is surely part of our holistic care? I love my job and I have fantastic staff who love their jobs too - don't make it even more difficult than it is already - let us have more time to do it well!

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  • I work in a nursing home as a clinical lead nurse. The home accommodates up to 35 residents many with complex nursing needs, numerous co-morbidity's including many receiving end of life care. Medication administration especially the morning round starts the pressure pot to boil. If I've left my shift 10-12hrs later having been able to go to the bathroom at least once it's been a good shift. One shift recently saw me admit a new resident whilst also trying to resolve and report a poor discharge, administer medications assist residents with personal care, accompany an unplanned Gp visit to 8 residents and administer flu vacs, write up these notes and inform next of kin re visit, tend to a dying residents syringe driver and it's controlled medication, visit a bathroom then hear the emergency bell go off, deal with the questions and expectations of family members and residents then sit with my resident and hold her hand after she had died feeling totally exhausted and tearful.
    Now I have been told I will lose clinical staff as hca's are being trained to assist medication rounds as it is more cost effective.
    All residents have been asked if they wish to self medicate, all have capacity, All have declined to do so. They have been involved in the decision process involving their medication. For those who may change their mind or new residents who wish to self medicate will this aid or hinder my shift?
    Will training a hca to administer non controlled medications aid or hinder my shift?
    I love being a nurse, I love my job and I love the privilege of caring for my residents and their families.
    Who will care for me when it goes t##s up?
    NICE please get your butts out of your offices and get to know HOW things really are in the REAL world PLEASE

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