CQC Outcome 9: Management of Medication Policy

Policy Statement

This policy is written to show how this care service complies with Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and Outcome 9: Management of Medicines of the Care Quality Commission’s Guidance about Compliance: Essential Standards of Quality and Safety.

Regulation 13 requires care providers “to protect residents against the risks associated with the unsafe use and management of medicines, by means of the making of appropriate arrangements for the obtaining, recording, handling, using, safe keeping, dispensing, safe administration and disposal of medicines”. In making their arrangements care providers “must have regard to any guidance issued by the Secretary of State or an appropriate expert body in relation to the safe handling and use of medicines”.

The medication policy covers:

  1.  self-administration of medication by residents
  2.  administration of medication including prescribing practices
  3.  use of controlled drugs
  4.  storage of medication
  5.  Disposal of unwanted medication.

With respect to the prescribing, supply, storage and administration of medicines, the care service is mindful of the need to be compliant with all other relevant legislation and guidance, particularly the Medicines Act 1968, the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973, the Nursing and Midwifery Council (NMC) Guidelines for the Administration of Medicines, and guidance issued by the Royal Pharmaceutical Society of Great Britain (2007).

This policy should be read and used alongside other related policies and procedures that address specific matters involved in the management of medication, including:

  1.  Controlled Drugs
  2.  Covert Medication
  3.  Homely Remedies
  4.  Drug Errors
  5.  Medication to be “Taken as Required”
  6.  Medication when the Resident is Away from the Home
  7.  Non-Compliance with Medication
  8.  Use of Oxygen

Medication Management Procedures

  1.  Woodlands & Hill Brow Ltd works on the principle that Residents have the right to manage and administer their own medication if they wish to and provides support and aids to enable safe self-administration wherever possible. However, to ensure their safety, and the safety of other residents, all residents must be assessed on a regular basis and will be considered for self-administration only if considered safe to do so. Records are kept of all medication prescribed to resident’s who self-administer and a secure area is provided in the resident’s room for the storage of self-administered medication, including safe storage of controlled dosage systems (blister packs), non-prescription and alternative remedies.
  2.  The choices made by resident’s — e.g. to administer and manage their own medication — are always respected by staff and recorded in the plan of care.
  3.  No assumption is made that a resident cannot self-administer their medication purely on the basis of their condition or mental capacity. Residents who are suspected to be lacking capacity are assessed according to the “best interest” principles contained in the Mental Capacity Act 2005. Where a resident can be enabled to self-medicate with additional support, or where they can self-administer parts of their medication, such support is provided.
  4.  All medication within the home is safely stored away, including blister packs, non-prescription medication, alternative remedies and self-administered medication. A lockable metal drug cabinet and lockable trolleys are provided for this purpose. The keys to the cabinet and trolley are always kept by the senior nurse or carer in charge or by a manager.
  5.  Neither the cabinet or trolley is ever left unlocked or unattended at any time and when not in use the trolley is secured to a wall. A lockable fridge is also provided for medication that needs to be kept cool. The temperature in this fridge is monitored daily. The normal foodstuff fridge should not be used to store medication.
  6.  All incoming medication is recorded in the stock record, including blister packs. Controlled drugs are recorded in the controlled drugs register. Incoming medication without a clear label stating name of patient, name of medication, expiry date, strength, dose, frequency of administration, start and finish times, must be referred to the community pharmacist.
  7.  Medication is always kept in its original packaging with the resident’s name clearly visible.
  8.  Medication is always administered by a registered first level nurse or by a designated, appropriately trained and competent member of staff.
  9.  Medication is only ever administered to a resident on the basis of their explicit consent or agreement to take the medication. The only exceptions are on rare occasions when medication is given without explicit consent on a “best interests” basis following policy and procedures relating to mental incapacity.
  10.  A separate medication record (MAR) chart is kept for each resident using prescribed medication. Staff must carefully check the identity of each resident to ensure that the correct record is being used and that the correct medication is being given to the correct person.
  11.  Staff must also check the medication name, the strength of the medication, the dosage instructions and the expiry date. Controlled drugs must always be double-checked by a second suitably trained member of staff. Complex dosage calculations must also be double-checked.
  12. Staff administering medication must at all times follow strict infection control principles – washing hands before and post administration of any drops such as eye and ear drops and using hand gel between residents.
  13.  All drug errors must be reported to the manager/nurse in charge or to a responsible medical practitioner without delay.
  14.  Staff are expected to be always aware of the medication being taken by individual residents and to report any change in condition that might be due to medication or side-effects immediately to the nurse in charge/manager. The nurse in charge/manager will then discuss the case with the prescriber, with another prescriber or with the community pharmacist.
  15.  All unwanted, surplus or out of date medication for disposal should be placed in the bins provided by the licensed waste disposal company. The consignment note from the licensed waste contractor should be retained as evidence of receipt. Controlled drugs must be denatured in the Controlled Drug Destruction kits (DOOP Kit) and recorded as destroyed in the Controlled Drug Register and double checked by two suitably trained members of staff. Used Control Drug patches on removal from the resident should be folded in half to inactivate them and placed in the DOOP kit for destruction.
  16.  When a resident passes away all their medicines are to be retained for at least seven days before disposal.


  1.  All new staff receives training as part of their induction covering basic information about common medicines and how to recognize and deal with medication problems.
  2.  All training follows the guidance issued by the Royal Pharmaceutical Society of Great Britain (RPSGB) in The Handling of Medicines in Social Care (2007). Staff are trained to the level required by their roles and responsibilities, which is reflected in the certification issued from the training.
  3.  Nursing staff are expected to keep themselves up to date as specified in the NMC Guidelines for the Administration of Medicines. Additional training will be offered to those fulfilling the Designated Person role.



Signed: ________________________________
Date: ________________________________
Policy review date: ________________________________