Pharmacists can have a very positive influence over the management of medicines within a care home setting.

The Royal Pharmaceutical Society publication “The Right Medicine: Improving Care in Care Homes” published in February 2016 demonstrated that pharmacists working as part of a multidisciplinary team can add significant value when responsible for the whole system of medicines and their use. This value was estimated to be in the region of £135 million a year¹.

This added value has been recognised by NHS England² who have committed to the recruitment of 240 pharmacy professionals (160 pharmacists and 80 registered technicians) to work within care homes.

As the community based experts in medicines pharmacists are ideally placed to provide advice on the management of medicines within a care home. Community pharmacists are often asked to conduct advice visits or medicines audits within the care homes that they service, but how many of us understand the inspection process of the care home regulator CQC and as such how do we know that the advice we are providing is appropriate?

The Care Quality Commission is responsible for regulating and monitoring the service provided by care homes within England and Wales, in a similar manner to the GPhC inspections of community pharmacy.

A CQC inspection is designed to ensure that the home meets the standards specified in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Management of medicines within care homes falls under Regulation 12 of the act.

Regulation 12 stipulates that:

“Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe”.

This regulation prevents people from receiving unsafe care and treatment and also prevents unavoidable harm or risk of harm.

The primary focus of the CQC inspection process is to assess the quality of care experienced by the care home residents.

Each inspection will involve a team of inspectors led by a CQC inspector. The size of the team will be determined by the size of the home and could include team members with specific skills such as dementia specialists, pharmacy inspectors or interpreters. The team may also include an expert by experience, these are people who have had personal experience of the type of care being inspected either personally or from caring for someone experiencing care.

The CQC inspection process is designed to assess whether the service is providing the high standard of care expected.

During each inspection five key questions are asked:

• Is the service safe? -are people protected from abuse and avoidable harm?
• Is the service effective? - does the people’s care, treatment and support achieve good outcomes, promote a good quality of life and is it evidence based?
• Is the service caring? – does the service involve and treat people with compassion, kindness, dignity and respect?
• Is the service responsive to people’s needs? -does the service meet people’s needs?
• Is the service well led? -  does the leadership, management and governance of the organisation assure a high-quality and person-centred care, support learning and innovation, and promote an open and fair culture?

Inspections can be either comprehensive or focused:

• Comprehensive inspections look at all of the five key questions, awarding a rating for each question and  an overall rating for the home
• Focused inspections investigate breaches of legal requirements or serious concerns that come to light after a comprehensive inspection

Before arriving at the home the inspection team will have collated intelligence on the home and its performance. This could include:

• Previous inspection reports
• Feedback or comment from people whose lives have been impacted by the service such as residents, and family members
• Feedback from agencies or organisations who have worked with or within the home such as:
  • the CCG or local authority who may commission the service
  • healthcare providers such as GP's, community or specialist nurses, community pharmacists, occupational therapists or physiotherapists
  • training providers
  • local advocates
  • community organisations such as day centres or lunch clubs

In order for community pharmacists to be able to support care homes in meeting the required standards, it is valuable to understand exactly what the inspectors will be looking for.

CQC inspectors will expect to see that the management of medicines within the home complies with NICE guidance SC1 Managing Medicines in Care Homes³. It is obviously important that pharmacists providing advice visits to care homes are familiar with this guidance.

The key medicines related question (known as a key line of enquiry) asked during an inspection is “How does the provider ensure the proper and safe use of medicines?”

To answer this question the inspection team will investigate eight specific aspects of medicines management within the home.

We will consider each of these eight aspects individually along with some examples of the types of evidence inspectors will be looking for to confirm that the medicines handling process within the home is both safe and effective. By understanding the types of evidence that the inspection team will be looking for pharmacists can ensure they provide effective and appropriate advice when conducting medicines advice visits for their care homes.

1. Is the service’s role in relation to medicines clearly defined and described in relevant policies, procedures and training? Is current and relevant professional guidance about the management of medicines followed?

Inspectors will expect the care home to have a comprehensive medicines policy that details all aspects of medicines handling within the care home. Numark members can access a template medicines handling policy from NumarkNet. 

Care home staff will be expected to be able to explain the care home policies and procedures, possible questions could involve:

• procedures for dealing with verbal instructions from prescribers to amend a patient’s medication
• how they would deal with a dispensing or medication administration error 
• how would they respond to fridge temperatures outside of the required temperature range
• processes within the care home to ensure that changes to a resident’s medicines are communicated to the pharmacy

Inspectors would also expect to see records of medicines management training that has taken place within the care home. Pharmacists asked to deliver training to care home staff can access the Numark Medicines Management training from by clicking here.

Care home staff should also be able to detail how they would access specific medicines related information, suitable sources could include healthcare professionals such as a pharmacist, GP, Community Nurse, Psychiatric Nurse or reference sources such as BNF, cBNF, MIMS, Summaries of Product Characteristics (SPC) or Patient Information Leaflets (PIL)

2. How does the service make sure that people receive their medicines (both prescribed and non-prescribed) as intended (including controlled drugs and ‘as required’ medicines), and that this is recorded appropriately?

Ensuring residents receive their medicines as prescribed is an essential part of patient care, as such inspectors will expect to see MAR charts that are accurate and completed at the time of administration.

Specific focus will be made for time sensitive medicines, such as Parkinson’s disease drugs to ensure that residents receive these medicines at a time that is clinically appropriate.

Records of administration of variable dose medicines should always include details of the dose that was actually given rather than a simple signature.

All “when required” medicines should be supported with a “when required protocol” in the residents care plan. This should document the symptoms that trigger administration of the medicine, the dose to be given, the effect the medicine should have along with the time-line, maximum daily dose and duration of use.

Care home staff should be able to explain the role of homely remedies within the care home including circumstances where it is appropriate for these medicines to be used, professional advice that is sought before using these remedies and the method of recording administration of these remedies.

3. How are medicines ordered, transported, stored, and disposed of safely and securely in ways that meet current and relevant legislation and guidance?

Care homes are required to ensure the continuity of medicine supply for their residents. This requires the home to have an ordering process that meets this requirement.

NICE guidance specifies that care home staff should be given protected time for ordering medicines and that each home should have at least two members of staff that have the training and skills to order medicines³. NICE also directs that care homes should retain the responsibility for ordering of medicines and that this should not be delegated to the pharmacy. The inspection team will expect the home to have a suitable ordering process.

Care homes should be encouraged to check prescriptions before dispensing to ensure that all medicines ordered have been prescribed.

The inspectors will also be checking that the home stores the medicines appropriately. Key considerations of the inspection team would include:

• Medicine security- including security of the medicines room, drugs trolleys and procedures for ensuring security of keys, including spare keys.
• Methods for ensuring stability of medicines- including monitoring and recording ambient and refrigerated temperatures daily, routine checks of expiry dates of medicines, recording dates of opening on liquid and external products to ensure they are used within their “open shelf life”
• Safe storage- including separating  internal and external products, checks on where thickeners and sip feeds are stored, monitoring general tidiness, organisation and cleanliness of medicines storage areas
• Disposal of medicines- suitable procedures for segregating, recording and disposing of obsolete or unwanted medicines
• Procedures for storage,  recording and destruction of controlled drugs that comply with Misuse of Drugs regulations

4. Are there clear procedures for giving medicines covertly, in line with the Mental Capacity Act 2005?

The care home would be expected to demonstrate compliance with all of the legal aspects of covert administration where residents are being administered medicines covertly.

Care home staff would be expected to explain how they would confirm that the proposed method for administering medicines covertly is safe and does not affect the clinical action of the medicine. Care home staff would typically ask their supplying pharmacist for this information. Numark Information Services can support members with providing this information.

A template form is available on NumarkNet that Numark members can use to provide this information to the care home.  Numark members wishing to increase their knowledge of covert administration can access the Pharmacy Excellence module on the training platform.

5. How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

Evidence of regular reviews of resident’s medicines would demonstrate that the home does not routinely use anti-psychotic or sedative medicines to control a resident’s behaviour.

The home would also be expected to demonstrate that residents have access to specialist medical services, such as community psychiatric teams, where necessary.

6. How do staff assess the level of support a person needs to take their medicines safely, particularly where there are difficulties in communicating, when medicines are being administered covertly, and when undertaking risk enablement assessments designed to promote self-administration?

The care home should have a procedure for assessing a residents’ ability to self-medicate; this should include the possibility of residents being able to manage some but not all of their medicines. The home should also have a procedure for monitoring patients who are self-medicating to ensure they remain able to do so safely.

The inspection team would expect that the care home staff would be able to explain how this process operates within the home.

Care homes should be able to provide self-medicating residents with facilities to securely store their medicines within their room.

7. How does the service engage with healthcare professionals in relation to reviews of medicines at appropriate intervals?

The care home is required to ensure that residents have access to healthcare services whenever needed; this should include a review of medication at regular intervals. NICE³ advises that all people over 75 years old should have their medication reviewed at least annually with those prescribed 4 or more medicines being reviewed 6-monthly.

The inspection team would expect care home staff to be able to explain the process for arranging a review of a resident’s medication.

The inspection team would also expect care home staff to be able to explain the home process for ensuring residents receive appropriate monitoring checks, such as INR checks, blood lithium or methotrexate levels or kidney function checks for ACE inhibitors, and that appropriate action is taken following these tests.

8. How do staff make sure that accurate, up-to-date information about people’s medicines is available when people move between care settings? How do medicines remain available to people when they do so?

Inspectors would expect care homes to have appropriate procedures for reconciling a resident’s medication when they first arrive within the home. These records should be confirmed with the resident's GP at the earliest opportunity.

Care homes should also have procedures for providing information regarding resident’s medication to other care providers such as hospitals, new GP's, other healthcare professionals and other care homes. This procedure should also include a process for supplying medication to accompany the resident. Medication should always be supplied in the original labelled container as supplied by the pharmacist.

Pharmacists wishing to understand further how CQC grades the service following an inspection and what they consider “good” to look like can access the guidance on the CQC website .

Numark members wishing to provide advice visits to their care homes can use the template visit form or visit e-form available to download from NumarkNet, these forms cover all aspects of medicines handling within a care home and also complies with NICE guidance on Managing Medicines in Care Homes

Visit form: 

E-form

1 The Right medicine Improving care in care homes: Royal Pharmaceutical Society February 2016
2 https://www.england.nhs.uk/2018/03/care-home-pharmacists-to-help-cut-over-medication-and-unnecessary-hospital-stays-for-frail-older-patients/ accessed May 2018
3 NICE medicines management in care homes