Unit 116: Support the use of Medication in Social Care

Settings

Candidates Work Book

Contents
Title

Page Number

Learner Profile
4
Form 4: Expert / Witness Status List
5
Form 9A: Evidence Location Sheets
6
Form 10: Unit Assessment and Verification
10
Declaration
Form 11B: Summary of Unit and Qualification
11
Achievement
Unit 116.1: Understand the Legislative Framework for the use of Medication in Social Care
Settings
Task 1.1
13
Task 1.2
17
Task 1.3
18
Task 1.4
18
Task 1.5
19
Unit 116.2: Know about Common Types of Medication and their use
Task 2.1
21
Task 2.2
23
Unit 116.3: Support the use of Medication in Social Care Settings
Task 3.1
25
Task 3.2
26
Task 3.3
27
Unit 16.4: Understand the Techniques for Administering Medication
Task 4.1
29
Task 4.2
30
Task 4.3
31
Unit 16.5: Be able to Receive, Store and Dispose of Medication Supplies Safely
Task 5.1
33
Task 5.2
34
Task 5.3
34
Task 5.4
35
Unit 116.6: Know how to Promote the Rights of the Individual when Managing Medication
Task 6.1
37
Task 6.2
38
Task 6.3
39
Task 6.4
39
Task 6.5
41
Unit 116.7: Be able to Support the use of Medication
Task 7.1
42
Task 7.2
43
Task 7.3
44
Task 7.4
45
Task 7.5
47
2

Unit 116.8: Be able to Record and Report on use if Medication

Task 8.1
Task 8.2
Task 8.3
Notes pages
Assessment Plan, Review and Feedback
Form 7: Questioning Evidence Record
Performance Evidence Record (x3)
Cornwall Council Department for Children,
Schools and Families Policy and Procedure
for the Administration, Control and
Recording of Medicines for Establishments
(CC126 Revision)
Medication Competency Assessment (DRAFT)
Cornwall Council Medication Form

49
49
49
50
53
56
58
70

81
85

Learner Profile
If you have a CV you can use that instead of this form.

Name

Place of Work

Outline of current job role

Previous relevant work roles and responsibilities, including voluntary work

Previous relevant qualifications and training

Form 4

Expert / Witness Status List

Qualification title: _________________________________________________________

Unit title: ________________________________________________________________
Candidate name: __________________________________________________________
Please ensure that all witnesses who have signed the candidates evidence or written a
report are included on this witness status list. All necessary details must be included and
signed by the witness as being correct.
Witness name and signature

Status*

Professional
relationship to
candidate**

Unit or outcomes
witnessed

Date

*Witness status categories

1. Occupational expert meeting specific qualification requirement for role of Expert Witness; 2.
Occupational expert not familiar with the standards; 3. Non-expert familiar with the standards; 4. Nonexpert not familiar with the standards.
**Professional relationship to candidate
Manager = M

Supervisor = S

Colleague = Coll

Customer = Cus

Other (please specify) __________

Assessor signature: ______________________________ Date: ___________________________

Form 9A

Evidence Location Sheet

Candidate name: __________________________________________________________

Unit number/title: 116.1 - Understand the legislative framework for the use of medication
in social care settings

Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence12

Direct Observation

Oral Questions

Witness Testimony

10

10

Unit number/title: 116.2 - Know about common types of medication and their use

Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence

Direct Observation

Oral Questions

Witness Testimony

Form 9A

Evidence Location Sheet

Candidate name: __________________________________________________________

Unit number/title: 116.3 - Understand roles and responsibilities in the use of medication in
social care settings

Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence

Direct Observation

Oral Questions

Witness Testimony

10

10

Unit number/title: 116.4 - Understand techniques for administering medication

Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence

Direct Observation

Oral Questions

Witness Testimony

Form 9A

Evidence Location Sheet

Candidate name: __________________________________________________________

Unit number/title: 116.5 - Be able to receive, store and dispose of medication supplies
safely
Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence

Direct Observation

Oral Questions

Witness Testimony

10

10

Unit number/title: 116.6 - Know how to promote the rights of the individual when
managing medication
Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence

Direct Observation

Oral Questions

Witness Testimony

Form 9A

Evidence Location Sheet

Candidate name: __________________________________________________________

Unit number/title: 116.7 - Be able to support use of medication

Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence

Direct Observation

Oral Questions

Witness Testimony

10

10

Unit number/title: 116.8 - Be able to record and report on use of medication

Item of evidence

Loc*

Ref

Link to assessment criteria ()

1

Written Evidence

Direct Observation

Oral Questions

Witness Testimony

Form 10

Unit Assessment and Verification Declaration

Qualification title: _______________________________________________________________________

Unit number and title: ____________________________________________________________________
Candidate Declaration
I confirm that the evidence listed for this unit is my own work.
Candidate name: ________________________________________________________________________
Signature: _______________________________________________________ Date: __________________
City & Guilds registration / unique learner number (ULN): _______________________________________
Assessor Declaration
I confirm that this candidate has achieved all the requirements of this unit with the evidence listed. (Where
there is more than one assessor, the co-ordinating assessor for the unit should sign this declaration.)
Assessment was conducted under the specified conditions and context, and is valid, authentic, reliable, current
and sufficient.
Assessor name: _________________________________________________________________________
Assessor signature: _______________________________________________ Date: __________________
Countersignature: (if relevant) ______________________________________ Date: __________________
(For staff working towards the assessor qualification)

Internal Verifier Declaration

I have internally verified the assessment work on this unit by carrying out the following (please tick):
sampling candidate and assessment evidence

Date:

discussion with candidate

Date:

observation of assessment practice

Date:

other please state:

Date:

I confirm that the candidates sampled work meets the standards specified for this unit and may be presented
for external verification and/or certification.
Not sampled
Internal verifier name: ____________________________________________________________________
Internal verifier signature: __________________________________________ Date: __________________
Countersignature: (if relevant) ______________________________________ Date: __________________
(For staff working towards the internal verifier qualification)

10

Form 11B

Summary of Unit and Qualification Achievement

Candidate name: ________________________________________________ Signature:__________________

City & Guilds registration number: __________________________________ Date: _____________________
Centre name: __________________________________________________ Centre number: _____________

Unit

Title

Internal Verification
Date

Types of
evidence
(see key)

Key for types of

evidence
(please extend if
necessary):

Grade
Signatures
achieved Assessor* Candidate IV*

(if
appropriate)

EV (if sampled)

O = Observation; Q = Questioning; P = Work products; C = Candidate/Reflective

account; S = Simulation; PD = Professional discussion;
A = Assignments, projects/case studies; WT = Witness testimony; ET = Expert
witness testimony;

*If there is a second line assessor/IV, both must sign.

Competence has been demonstrated in all of the units/the qualification recorded above using the
required assessment procedures and the specified conditions/contexts. The evidence meets the
requirements for validity, authenticity, currency, reliability and sufficiency.
Internal Verifier signature: _______________________________________ Date: _____________________

11

Unit 116 /1:

Understand the Legislative Framework for the use of

Medication in Social Care Settings

12

TASK 1.1
Identify legislation by completing the table below and outline what the law states about the
use of medicines in social care settings.

Legislation

Identify Key Points

Disability Discrimination Act 1995

SEN & Disability Act 2001

Health & Safety at Work Act 1974

Control of Substances Hazardous to

Health Regulations 2002

13

Misuse of Drugs Act 1971

& Misuse of Drugs Regulations 2001

The Data Protection Act 1998

Hazardous Waste Regulations 2005

The Human Rights Act 1998

14

The Health & Social Care Act 2001

The Education Act 1996

The Children Act 1989

Mental Capacity Act 2005

15

NMC Code of Conduct Safe Handling

of Medicines

Care Standards Act 2000

Access to Health Records Act 1990

Administration and Control of

Medicines in Care Homes and
Childrens services 2003

16

TASK 1.2
Legal classification of medicines
There are various legal controls over the sale and supply of medicines as set out in the
Medicines Act 1968. The Act classifies the medicines into three categories. Using the table
below, outline each category.

Classification Category

Description of Term

Prescription Only (POM)

Pharmacy (P)

General Sale List (GSL)

17

TASK 1.3
Using the space below outline the main points from your settings medicine policies and
procedures and explain your role and responsibility.
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TASK 1.4
Think about your policy and state three ways it reflects and incorporates legislative
requirements.

18

TASK 1.5
Explain below why it is important for settings to have a policy in place for the administering of
medication and why it is important to reflect and incorporate legislative requirements.
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19

Unit 116.2:

Know about Common Types of Medication and their use

20

TASK 2.1
Most people will need to take medication at some point in their lives, no matter how
healthy they are. There are huge numbers of different medications available and they are
developed to provide the best possible treatment for various health conditions.
Medication must always be taken properly and the correct doses as prescribed by doctors
and pharmacists should be strictly adhered to. Advice should also be sought before taking
medication as not all medications are suitable for everyone.
Using the table below list common medications, conditions for which they may be
prescribed and the possible side effects and adverse reactions a person may have to these
medications. An example has been given for you.
Type of Medication
Paracetamol

Conditions
Headache, muscle ache,
dental pain

Side Effects/Adverse
Reactions
Skin rash, damage to kidney
and liver and disorders
affecting the blood

21

22

TASK 2.2
Reflecting on your own personal practice describe a scenario where you have had to
administer medication to a child or young person outlining the medication and the
condition for which it has been prescribed. Has this child ever had an adverse reaction to
this medication? If so explain how you dealt with this.

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23

Unit 16.3: Support the use of Medication in Social Care Settings

24

TASK 3.1
Prescribed medication will be clearly labelled. List below information that will be found on
the label of prescription medication.

25

TASK 3.2
Complete the table below describing the roles and responsibilities in the use of medication
in a social care setting.

Person involved in medication

Roles and Responsibilities

Prescribing

Dispensing

Supporting use of medication

26

TASK 3.3
Describe below your settings policies and procedures for administering over the counter
remedies and supplements and your responsibility in relation to use of such medicines.

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27

Unit 116.4: Understand the Techniques for Administering Medication

28

Medication route refers to the way that a medicine is introduced into the body. This is
determined by the type of medication being administered, the desired absorption rate
and the specific site of action (where the medication needs to have an effect).

TASK 4.1
Describe the medication routes below:
Oral:

Sub Lingual:

Enteral:

Mucosal:

Parenteral:

Inhalation:

Intranasal:

Topical:

Rectal:

Transdermal:

Subcutaneous ingestion:
29

TASK 4.2
There are many different forms of medication. Use the format below to list and briefly
describe the commonly used types. An example has been given for you.

Tablets
swallowed orally

Forms of
medication

30

TASK 4.3
Describe how the following items of equipment are used in the administration of medication
and why they are important.

Calibrated Spoons:

Droppers:

Medicine Cups:

Oral Syringes:

Nasogastric Tube:

Hypodermic Syringes:

Gloves:

31

Unit 116.5: Be able to Receive, Store and Dispose of Medication Supplies

Safely

32

TASK 5.1
Read the statements below and tick the appropriate box for each statement

Statement about Medication

True

False

You should know the name, dosage and side effects, if any,
of all medications you are responsible for administering
You should always follow the instructions on the label
carefully
It is ok to transfer drugs from one container to another
Unused medicines can be disposed of with everyday waste
It is ok to change a medication schedule without first
checking with a doctor
You should always obtain parental consent to administer
medication to a child or young person
Used hypodermic needles should be disposed of in a sharps
bin
Over the counter medications can be taken for as long as
needed without seeking medical advice
Always reorder repeat medication before you run out of it
If an error occurs when administering medication it must be
reported immediately and emergency medical advice
obtained
You can double a dose of medication if the previous dose
was forgotten
Medication should be stored away from children
If two people use the same medication it is ok to use the
other persons sometimes
Untrained people can administer medication such as EPI
pens
Medicines should be stored at the correct temperature
Some medication will need specialist training to administer
to patients
If an individual vomits after being given a dose of medication
it is ok to give another dose immediately

33

TASK 5.2
Describe how you receive medication in your setting in line with agreed ways of working
and following organisational policies and procedures.
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TASK 5.3
Explain the storage systems in place for medication in your setting and the reasons why
these may differ depending upon the medication.
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34

TASK 5.4
List 4 possible situations where it may be necessary to dispose of medication.

1. ___________________________________________________________

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2. ___________________________________________________________
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3. ___________________________________________________________
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4. ___________________________________________________________
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___________________________________________________________

Describe how you dispose of unused or unwanted medication safely and explain why this is
important.
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35

Unit 116.6: Know how to Promote the Rights of the Individual when
Managing Medication

36

TASK 6.1
Using the table below explain the importance of these principle in the use of medication.

Principle

Importance

Consent

Self-Medication or Active
Participation

Dignity and Privacy

Confidentiality

37

TASK 6.2
Explain how you can promote an individuals independence when managing medication and
how risk assessment can be used to promote this.

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38

TASK 6.3
List below types of medication that you should be aware of that may require the necessity
for privacy and respect for an individuals dignity and then explain why this is important.

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

TASK 6.4
Using a blank risk assessment form from your setting, identify risks and hazards that could
occur when allowing an individual to self-medicate or as an active participant.

39

TASK 6.5
Using the format below, list ethical issues that could arise over the use of medication and
then give a brief explanation how these issues can be addressed.

Ethical Issues

40

Unit 116.7: Be able to Support the use of Medication

41

TASK 7.1
It is essential that any child or young person in your care has up to date information
kept about them detailing their medical history and any medications that need to be
administered by carers in the setting. Describe below how information is kept in your
setting and how you access this information to ensure the correct medication is given
and in the correct manner.
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42

TASK 7.2
Using reflection on your own practice write an account about how you have
supported an individual to use medication in a way that ensures and promotes safety
and dignity, hygienic practice and where possible active participation.
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43

TASK 7.3
Before administering medication to a child or young person there are procedures you
need to think about to ensure it is administered correctly. List and briefly describe
these procedures below.

44

TASK 7.4
Using the table below describe how you address practical difficulties that may arise
when administering medication.

Practical Difficulties

Solution

Lost medication

Missed medication

Spilt medication

An individuals decision not to take

medication

45

Difficulty in taking medication in its

prescribed form

Adverse reaction

Wrong medication used

Vomiting after taking medication

Discrepancies in records for directions of use

46

TASK 7.5
As you have learnt through previous tasks, there are many different types of medication and
routes it can be administered. Some types of medication may only need to be administered
occasionally if symptoms arise and others on a regular basis.
List below the types of medication that you would need extra training to administer to a
child or young person and describe how you would access further information and support
about the use of such medicines.

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47

Unit 116.8: Be able to Record and Report on use of Medication

48

TASK 8.1
Using a medication form from your setting think of a real or fictitious scenario where you
would administer a medication and complete the information. If using a real situation you
must use a fictitious name to ensure confidentiality.

TASK 8.2
Highlight the statements in the table below that will help ensure you keep accurate and
clear records of medication for individuals.
Writing clearly and neatly
Drawing doodles to make the records more
fun
Being detailed and relevant
Writing your own opinion wherever possible
Changes in behaviour clearly noted

Keeping records free from dirt and spillages

Keeping the information up to date
Using as many long words as possible
Keeping records tidy and organised

TASK 8.3
Describe lines of reporting problems associated with medication and who you would report
your concerns and findings to in line with your settings agreed ways of working.
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49

Notes page:

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50

Notes page:

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Notes page:

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52

Assessment Plan, Review and Feedback

Learner name

Assessor name

Unit number(s) and title(s)

This record can be used for planning, reviews, feedback, progress reviews and details of
contact. Remember that all planning should be SMART Specific, Measurable,
Achievable, Realistic and Time Bound. This should be on-going and completed every time
learner and assessors meet.
58
Date
action
agreed

What has to be done / What has been reviewed and the feedback
/ Record of judgment or outcome / action targets

Date to
be done
by / Date
done

Learnerand
assessor
signatures

Evidence
reference

53

Date
action
agreed

What has to be done / What has been reviewed and the feedback
/ Record of judgment or outcome / action targets

Date to
be done
by / Date
done

Learnerand
assessor
signatures

Evidence
reference

54

The above is an accurate record of the discussion.

Learner signature

Date

Assessor signature

Date

55

Form 7

Questioning Evidence Record

Unit:

Support Use of Medication in Social Care Settings

Candidate name: _____________________________________________________________________

Unit

116

116

116

116

Learning
outcome(s)

Assessment
criteria

Questions

Which legislations are most

significant to administering
medicine in social care
settings?

What are the most common

types of medicines
administered to children in
your care?

Where do your settings

responsibilities lie with
administering over the
counter medication?

Answers

What equipment may be used

to administer medication?

The above is an accurate record of the questioning.

Candidate signature: ______________________________________________ Date: __________________
Assessor signature: _______________________________________________ Date: __________________
Internal Verifier signature (if sampled): _______________________________ Date: __________________

56

Form 7

Questioning Evidence Record

Unit:

Support Use of Medication in Social Care Settings

Candidate name: _____________________________________________________________________

Unit

116

Learning
outcome(s)

Assessment
criteria

116

116

116

Questions

Answers

How do your store medication

in your setting to ensure their
safe keeping?

What ethical issues may arise

when administering
medication and how may
these be addressed?

What strategies are in place to

ensure medication is
administered correctly?

How do you record the use of

medication and any changes
that may occur with the
individual?

The above is an accurate record of the questioning.

Candidate signature: ______________________________________________ Date: __________________
Assessor signature: _______________________________________________ Date: __________________
Internal Verifier signature (if sampled): _______________________________ Date: __________________

57

Performance Evidence Record

Qualification/unit

Learner name

Use this form to record details of activities (tick as appropriate)

Evidence ref(s):

Observed by your assessor

Unit number(s):

Seen by expert witness

Seen by witness

Self / reflective account

NB. Your assessor may wish to ask you some questions relating to this activity. There is a
separate sheet for recording these. The person who observed/witnessed your activity must
sign and date overleaf.

Date of Activity
Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

58

Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

59

Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

60

Assessment decisions and feedback to learner

I confirm that the evidence listed is my own work and was carried out under the conditions
and context specified in the standards.

Learner signature

Date

Assessor/Expert Witness* signature

Date

*delete as appropriate

Internal Verifier signature (if sampled)

Date

61

Performance Evidence Record

Qualification/unit

Learner name

Use this form to record details of activities (tick as appropriate)

Evidence ref(s):

Observed by your assessor

Unit number(s):

Seen by expert witness

Seen by witness

Self / reflective account

NB. Your assessor may wish to ask you some questions relating to this activity. There is a
separate sheet for recording these. The person who observed/witnessed your activity must
sign and date overleaf.

Date of Activity
Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

62

Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

63

Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

64

Assessment decisions and feedback to learner

I confirm that the evidence listed is my own work and was carried out under the conditions
and context specified in the standards.

Learner signature

Date

Assessor/Expert Witness* signature

Date

*delete as appropriate

Internal Verifier signature (if sampled)

Date

65

Performance Evidence Record

Qualification/unit

Learner name

Use this form to record details of activities (tick as appropriate)

Evidence ref(s):

Observed by your assessor

Unit number(s):

Seen by expert witness

Seen by witness

Self / reflective account

NB. Your assessor may wish to ask you some questions relating to this activity. There is a
separate sheet for recording these. The person who observed/witnessed your activity must
sign and date overleaf.

Date of Activity
Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

66

Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

67

Unit(
s)

Learning
outcome
(s)

Assessment
criteria

Evidence

68

Assessment decisions and feedback to learner

I confirm that the evidence listed is my own work and was carried out under the conditions
and context specified in the standards.

Learner signature

Date

Assessor/Expert Witness* signature

Date

*delete as appropriate

Internal Verifier signature (if sampled)

Date

69

CORNWALL COUNCIL
DEPARTMENT FOR CHILDRENS ,SCHOOLS AND FAMILIES

CC126 Revision

Community Care Service Policy and Procedure

POLICY AND PROCEDURE FOR THE ADMINISTRATION, CONTROL AND RECORDING OF MEDICINES
FOR ESTABLISHMENTS

1.

Policy Statement

1.1

People accessing Day Services or Short Break Care provided by Cornwall Council Department
of Adult Social Care should be encouraged to retain, administer and control their own
medication in order to maximise their independence and retain control over their own lives.
This will require risk assessment, including Mental Capacity assessment, to ensure the safety
of the person and of others.

1.2

Some people will be assessed as able to self-medicate, while others, i.e. children and young
people within Children, Schools and Families will need assistance. In these cases staff will
need to take complete responsibility for the safe keeping and administration of medicines.

2.

Definitions

2.1

Controlled drugs These are medicines with the potential for abuse for which special legal
precautions are necessary. A current list of these can be obtained from
http://drugs.homeoffice.gov.uk or individual queries can be made to the community
pharmacist.

2.2

MAR sheets medication administration record sheets that show the

administration to a service user. See SC/270 (Sample No. 204)

2.3

Consent Where people are deemed by a health professional to lack the mental capacity to
consent, their carer or advocate may do so on the grounds that it is in the persons best
interests.

3.

Legal Framework

3.1

Medicines Act 1968 and amendments

Misuse of Drugs Act 1971 (Controlled Drugs) and amendments
COSHH Regulations 1999
Care Standards Act 2000 (Receipt, storage and administration of medicines)
Access to Health Records Act 1990
Data Protection Act 1998
Hazardous Waste Regulations 2005
Administration & Control of Medicines in Care Homes and Childrens Services June 2003
Mental Capacity Act 2005

individual

70

4.

Pharmacy Advice

4.1

Cornwall & Isles of Scilly PCT has an arrangement with community pharmacists to provide
advice and guidance to service users and staff. This Service Level Agreement is in line with
National Minimum Standards and requires participating pharmacists to offer advice and
support regarding:

proper and effective ordering of drugs

clinical and cost effective use
safe storage, supply and administration
proper record keeping.

5.

Categories of Medications

5.1

The law distinguishes between different categories of medicine. The categories are:

Prescription only medicine obtained on a prescription from the doctor, dentist or

nurse prescriber.

Controlled drugs specific medicines such as Morphine, Diamorphine (heroin),

Cocaine, Pethidine, etc. Because of the potential for misuse, special additional
restrictions apply to the prescription, storage, administration and recording of these
drugs.

Pharmacy medicine may only be purchased from a community pharmacy (chemists

shop) with the pharmacist present.

General sales list medicine (examples include paracetamol, proprietary cold

remedies like Lemsip, etc.) can be purchased through a wide variety of retail
outlets such as supermarkets and garages.

6.

Responsibility for Drug Administration

6.1

It is the overall responsibility of the Establishment Manager to ensure that a safe

environment exists in relation to the storage, administration and disposal of medicines
belonging to service users that have been handed in for safekeeping or for staff to
administer. The Manager must promote a safety conscious approach in which all staff
involved understand what is expected of them.

6.2

All new staff should read and understand the policy and procedure for the administration,
control and recording of medicines and sign to confirm understanding of this policy.

6.3

All staff should have access to the British National Formulary and any other appropriate
literature to assist with identifying medication and administration of such.

6.4

The Establishment Manager is responsible for ensuring only staff who have been trained
administer medication. (See Section 19)

6.5

The Manager, or a named officer to whom the manager has delegated responsibility, is
responsible at any given time for:
71

the security of medication including the possession of keys

the receipt of medicines
the administration of medicines to particular service users
the recording of the administration of medicines
the recording of the disposal of medicines.

6.6

A risk assessment for each service user should determine the support they need with
medication with this being reviewed on an annual basis or earlier when there is a change of
circumstances.

7.

Supply of Medicines

7.1

Medicines are those prescribed by a health professional. Only medicine prescribed for the
individual user may be administered to that person. Prescribed medicines belong to the
named individual and must not be given to anyone else.

7.2

The total amount of medicine prescribed is specified on each container, which makes it
easier to check if the medicine has been taken correctly. The pharmacist may add
instructions to the label such as complete the course or avoid alcohol. Should any detail
on the label not be clear staff must contact the pharmacist or health professional until they
are satisfied that sufficient instructions have been given.

8.

Security of medicines

8.1

Medication should arrive in original containers correctly labelled with the doctors
prescription and initially accompanied by a signed and dated service user/parent/carer
consent form. If this procedure is not adhered to the manager should refer to a Senior
Manager.

8.2

Medicine cabinets must be locked at all times except when in use. (This cabinet must be
locked if the nominated officer leaves the area to administer medication).

8.3

Access is restricted to the nominated officer only.

8.4

Keys to the medication cabinets need to be held personally by the nominated officer; either
on the person or in a safe and appropriate place overseen by the nominated officer.

8.5

Controlled drugs should be stored in a cabinet with an inner locked section in accordance
with the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 as amended.

8.6

When off the premises, medication should be stored in a secure container and carried by the
nominated officer.

9.

Storage of medication

9.1

A record of all medication received by the service must be kept.

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9.2

All medicines must be stored in the packages/containers as dispensed by the doctor or

pharmacist.

9.3

Every establishment must have a locked medicine cabinet available for the storage of
medication and any over the counter preparations that have been brought to the
establishment by service users.

9.4

Only medicines to be stored in the medication cabinet.

9.5

If a medicine requires refrigeration, it must be kept in a separate drug refrigerator, or in

exceptional circumstances in a secure lockable container in
a general refrigerator.

9.6

All medicines belonging to service users should be stored in individually

labelled areas within the medication cabinet.

9.7

Medicines for internal use should be stored separately from medicines for external use in a
separate locked cabinet or physically separated on different shelves. Disinfectants and
other potentially harmful chemicals should be stored in a separate locked cupboard.

10.

Disposal of medication

10.1

The Manager/Duty Officer or nominated officer will check all medication cabinets monthly
and record this procedure to ensure:

only medication is being stored in the cabinet

all medication is clearly labelled and in date

there is the minimum amount of service users medication stored in cabinets.

10.2

Any medication which is out of date or no longer required needs to be returned to the
pharmacist or sent back to parents/carers for disposal.

10.3

When returning controlled drugs ensure the pharmacist signs the controlled drugs book.

10.4

On the unexpected death of a service user it is important that any personal medication and
record sheets are kept until otherwise advised.

11.

Records

11.1

Each service user must have an up to date Agreement for the Administration of Medication
Form SC/269 (Sample No. 203) on file. It will be the responsibility of the Manager or
nominated officer to ensure these are regularly checked at least annually and kept up to
date.

11.2

The Manager or nominated officer must ensure that a written record using the MAR Sheet
SC/270 (Sample No. 204) is kept of all medication entering the establishment that is being
73

administered to service users, leaving the establishment at the end of a session or sent for
disposal. The records must contain:

date of receipt of medication entering the establishment

name and strength of the medication
quantity received
service for whom the medication is prescribed
signature of the members of staff receiving the medication.

11.3

For those service users who have epilepsy, the Manager or nominated officer will be
responsible for ensuring there is a current and up to date epilepsy profile and care plan on
file.

11.4

When preparing a medication record for a service user, the Manager or nominated officer
needs to ensure that they record each medication a person takes. The name, form, route,
strength, dosage and times of each medication need to be recorded clearly.

11.5

The Manager or nominated officer must ensure that any particular instructions e.g. allergies,
soluble, with/before/after food, etc, is recorded on the MAR Sheet SC/270 (Sample No. 204).

11.6

The nominated officer who has prepared the record must sign to verify the procedure. A
second officer then needs to sign the record sheet, confirming that the details are correct.
These details must be checked against the current Form of Agreement for Administration of
Medication SC/269 (Sample No. 203) and the previous MAR Sheet SC/270 (Sample No. 204).
If there are any doubts or confusion about medication or dosage instructions, then the
medication must not be given until this has been confirmed with either one or a
combination of those people listed below:

parents/ carers
doctor/ GP
community pharmacist
duty doctor.

This must then be clarified with the Manager.

11.7

The appropriate recording box must be initialled after medication is given. Staff need to
ensure that the correct box has been initialled i.e. time and date.

11.8

Quantities of regularly prescribed medication should be entered in the shaded

IN box under the correct date. Likewise, medication being signed out needs to be entered in
the OUT box. Liquid medication needs to be estimated by
volumes (not measured) e.g. or bottle. When signing medication OUT, two staff must
witness that the totals of medication being signed OUT must equal the amounts of
medication signed IN and ADMINISTERED during the stay.

11.9

For reasons of hygiene, medication should not be directly handled. Medication should be
counted by using a spatula or counting triangle.

11.10

Any medication coming directly from a pharmacy also needs to be counted in and recorded.

74

11.11

Any medication returned to the pharmacy or parent/carer for disposal needs to be recorded
on the back of the medication sheet and signed for by the nominated officer and the
witness.

11.12

As required medications need to be signed in and out using the back of the MAR Sheet
SC/270 (Sample No. 204).

11.13

Any liaison with parents/carers or doctors etc regarding medication needs to be recorded on
the back of the MAR Sheet SC/270 (Sample No. 204) and in the individual service users
Contact Sheet Form SC/10 (Sample No. 21).

11.14

If there are occasions when an urgent amendment needs to be made to the MAR Sheet
SC/270 (Sample No. 204) this must be made in ink with the person making this amendment
signing and dating this entry.

11.15

Completed sheets must be kept in the service users personal file.

11.16

If there are service users who have been prescribed controlled drugs then a separate
controlled drugs register with numbered pages must be maintained. In addition to the above
guidance for the receipt of medication, this bound book needs to include the balance
remaining for each product following each administration, with a separate record page for
each service user taking a controlled drug. There should be no crossing outs or obliterations
of any kind in this record.

12.

Administration

12.1

Staff administering medication will be expected to work towards achieving a relevant

certification. (See Section 18 Training)

12.2

Each service users medication has been prescribed specially for them and must not be
administered to anyone else, even if another service user is on the same medication and
dosage.

12.3

When administering medication, staff need to check that this is in accordance with the
instructions on the medication containers and on the MAR Sheet SC/270 (Sample No. 204).
If there are any discrepancies, refer to the Form of Agreement for Administration of
Medication SC/269 (Sample No. 203) or to parents/carers or the GP/pharmacist as necessary
(see 11.6).

12.4

Medication needs to be administered directly from the original labelled container. The
removal of medicines from their original containers into other containers by anyone is not
acceptable as such secondary dispensing increases the risk to both staff and service user.

12.5

The nominated officer is responsible for ensuring they are aware of all service users times
for administration of medication and of any special instructions e.g. to be taken with food.

12.6

It is not acceptable to covertly administer e.g. in food or drink, unless specifically instructed
by the prescriber.

12.7

Both the nominated officer administering the medication and the witness need to check:
75

the service user is correct

the medication is correct
the amount is correct
the time and date is correct
the expiry date.

12.8

The staff member should explain to the service user what they are about to do and
wherever possible obtain their consent. This will involve a capacity judgment. If the service
users capacity fluctuates this judgment must be made on each occasion. If capacity is static
then this must be documented and therefore a judgment would not need to be made each
time.

12.9

Both staff (nominated officer and witness) must visually witness that the service user has
taken the medication.

12.10

If a service user refuses a medicine, staff cannot force treatment. Advice should be taken
from the carer, GP or community nurse.

12.11

If medication is not administered for any reason an X needs to be recorded in the

appropriate box and the reason recorded and signed on the back of the MAR Sheet SC/270
(Sample No. 204) and also the service users Contact Sheet SC/10 (Sample No. 21).
For gross errors e.g. wrong tablet, wrong dose, wrong service user etc advice must be sought
immediately from the GP or pharmacist etc. Also the Manager/Duty Officer should inform
their Line Manager.
If the medication has not been signed for, this needs to be followed up immediately. If it is
then confirmed that the medication was given, a note of this needs to be written on the
back of the persons medication sheet. Medication MUST NOT be signed for in retrospect.
If it is not possible to contact the member of staff for confirmation, this will also need to be
recorded on the medication sheet and a count made of the persons medication to establish
if there is a high probability that the medication was given or not. If in doubt seek further
advice.

12.12

The witness to the administration of medication must sign for these on the MAR Sheet
SC/270 (Sample No. 204), alongside the nominated officers signature. Staff must only sign
their name to the specific service users they have actually witnessed.
If there is an RGN on the premises who administers medication a witness is not needed.
However it is good practice to have a second person as a witness.

12.13

The Duty Officer/Manager will check and ensure all relevant medications have been
administered and any discrepancies/queries will be followed up immediately by the Duty
Officer with the individual staff member.

13.

As required medication including the administration of emergency

medication

13.1

Any medication that is taken as required needs to be entered in its separate section on the
MAR Sheet SC/270 (Sample No. 204).
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13.2

Each time these medications are administered, the time, date and person administering
them needs to be recorded in the appropriate box and witnessed.

13.3

In the event of an emergency whereby any invasive treatments are necessary, such as
suppositories, including rectal Diazepam can only be administered by suitably trained staff.
Confirm with the Form of Agreement for Administration of Medication SC/269 (Sample No.
203) and refer to care plan or parents/carers for details on administration. Sensitivity is
required when administering this procedure. Ensure privacy and dignity for the service user
when carrying out this procedure.

13.4

If there is no suitably trained member of staff available to administer emergency medication

the emergency services must be called.

14.

Homely Remedies

14.1

These are intended for the occasional treatment of headache, stomach ache, etc. They are
not for regular use. If a service user requires repeated doses of home remedies the GP
should be informed. Agreement for the administration of any home remedies should be
clarified with the GP in question and recorded on the service users file.

14.2

A home remedies list should be compiled by each establishment and kept for reference, and
signed by a pharmacist or GP.

14.3

Purchased medicines, such as cough or cold remedies, contain several drugs which could
interfere with prescribed medicines. Advice should be sought from the pharmacist before
purchasing home remedies.

14.4

Details should be entered on the Form of Agreement for Administration of Medication

SC/269 (Sample No. 203) for reference by appropriate parent/ carer.

14.5

The administration of any home remedies should be recorded by the nominated officer and
witnessed on the service users MAR Sheet SC/270 (Sample No. 204).

15.

Self administrating

15.1

An assessment of mental capacity should be carried out by an appropriate assessor before

self medicating is carried out. This must be supported by robust risk assessments. These
assessments should be reviewed via the Care Planning process in order that this procedure
is still appropriate. The decision represents a balance between informed choice and risk to
the individual or other service users. The Form of Agreement for Self Administration of
Medication SC/271 (Sample No. 205*) should be signed by the service user, parents/carers,
doctor and Manager/Duty Officer and kept in the service users file. The Criteria Checklist
for Service User Assessment to Self Administer Medication should also be filled in at this
time - Form SC/596 (Sample 206).

15.2

Staff should monitor that the service user keeps their medicines secure at all times and they
do not pose a risk to others. A lockable storage locker/drawer/ container should be made
available for each self medicating service user to use, should they so wish, to which the
service user and Manager/Duty Officer have a key.
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15.3

If there is concern about the service users ability to administer their own medicines safely,
the Manager and health professional together with the service user and their carer and
families, agree how much responsibility the service users is able to undertake.

15.4

Discreet checks should be made by staff to ensure that the medicine is being taken correctly
and stored safely.

15.5

Should a service user be assessed as no longer able to safely administer

their own medication for whatever reason, staff should explain why the
decision has been reached.

16.

Service users who are temporarily absent including day trips and
outside activities

16.1

If the service user self medicates then staff should confirm that the
sufficient for the duration of the event.

16.2

If the service users medication is administered by staff, the Manager/Duty Officer must
arrange for medicines to be taken in their containers and given to a delegated member of
staff for administration and safekeeping.

16.3

If the service users medication is usually administered by staff but the service user is not
being accompanied by establishment staff, the Manager/Duty Officer must satisfy
themselves that the accompanying person has the authority and is competent in the
administration of these medicines. If satisfied, the Manager/Duty Officer will arrange for
those medicines to be taken in their containers and given to that person for administration
and safekeeping. If the Manager/Duty Officer is not satisfied that this person does not fulfil
both of these criteria the medication must remain in the establishment. In such a case the
Manager/Duty Officer must clearly inform both the service user and the person
accompanying them the time of the next administration of medicines and ensure this has
been understood.

16.4

It is good practice and required by this policy that administration of medication be recorded
by two members of staff on the MAR Sheet SC/270 (Sample No. 204). However there are
occasions, such as member of staff accompanying a small group or an individual service user
on a trip into the town, where this is impractical. In such cases it is permissible for one
member of staff to undertake both the administration and the recording of this provided a
written risk assessment has been carried out and any necessary controls put in place. The
administration of the medicine will be recorded on the MAR Sheet SC/270 (Sample No. 204)
with an explanation on the back of the sheet and on the relevant contact sheet.

service user has

IMPORTANT This variation cannot be used for the administration of controlled drugs
where two separate members of staff must be involved in the administration and witnessing
of such medications.

17

Equality and Diversity - Promoting Choice

17.1

Staff may with the consent of the service user administer prescribed medication, so long as
this is in accordance with the prescribers directions. However consent does not mean that a
78

service user may at any time refuse to take the medication that the member of staff offers.
(See Section 12)
17.2

Service users will also have certain preferences and these may relate to equality and
diversity. The following are of particular concern:

the medication is provided in a gelatine capsule and the resident is vegetarian

service users prefer to have medication given to them by a member of the same sex
the service user observes religious festivals by fasting and prefers not to have
medicines given at certain times.

17.3

These specific examples of service user choice and preference should be recognised and
accommodated through the care planning process.

18.

Training
18.1
All medicines can only be administered by designated and appropriately trained staff. See
also Professional Advice: Training care worker to safely administer medicines in care homes.
www.cqc.org.uk or Ofsted the current inspection body for Childrens Homes at
enquiries@ofsted.gov.uk

18.1

There are three levels of training for care staff.

All staff should receive level 1 (induction).
Level 2 (basic) is essential before any member of staff can administer medication.
Level 3 (specialised techniques) relates to those circumstances following an assessment by a
healthcare professional including:

rectal administration, e.g. suppositories, diazepam (for epileptic seizure)

insulin by injection
administration through a Percutaneous Endoscopic Gastrostomy (PEG)
giving oxygen.

18.3

Members of staff can refuse to administer medication if they consider they have not
received suitable training and do not feel competent to do so.

19.

Principles for the administration of medicine

19.1

In exercising professional accountability in the best interests of service users, staff must:

know the therapeutic uses of the medicine to be administered, its normal dosage,
side effects, precautions and contra indications

79

be certain of the identity of the service user to whom the medicine is to be

administered

be aware of the service users care plan

check that the prescription, or the label on a medicine dispensed by a pharmacist, is

clearly written and unambiguous

have considered the dosage, method of administration, route and timing of the
administration in the context of the condition of the service user and co-existing
therapies

check the expiry date of the medication to be administered

check that the service user is not allergic to the medication before administering it

contact the prescriber or another authorised prescriber without delay where contraindications to the prescribed medication are discovered, where the service user
develops a reaction to the medication, or where assessment of the service user
indicates that the medication is no longer suitable

make a clear, accurate and immediate record of all medication administered,

intentionally with-held or refused by the service users, ensuring written entries and
the signature are clear and legible, using its generic or brand name where
appropriate and its stated form, together with the strength, dosage, timing, and
frequency of administration, start and finish dates and route of administration. It is
also the staff members responsibility to ensure that a record is made when
delegating the task of administering medication in the case of controlled drugs,
specify the dosage and the number of dosage units or total course.

Nigel Stephens March 2008

Amended re CSF July 2009
Reviewed January 2011

80

Area / subject assessed

Organisation
Approach to whole procedure
General preparation / environment
Preparation of equipment
Appropriate environment
Personal preparation
Maintaining privacy and dignity

Relationship and communication

With the child understands the childs communication
methods
Age appropriate preparation for the child
Support during administration
With the assessor
With other staff
Information for the child and parents
Know where to go for help and support

Procedure
Performs appropriate hand washing, correctly and at the
appropriate times
Read and understand administration procedures /
guidelines medicines management policy (including
controlled drugs)

Assessors comments (discuss areas

of strength and areas for improvement
further learning)

Assessed by
Observation
Questioning
Documentation
Reflection
Discussion

Pass Refer list

actions taken
and review
date

Area / subject assessed

Assessors comments (discuss areas

of strength and areas for improvement
further learning)

Assessed by
Observation
Questioning
Documentation
Reflection
Discussion

Pass Refer list

actions taken
and review
date

Knowledge of the 6 Rs
Checking prescription, drug labels and instructions
Expiry dates
Preparation and administration of the drug(s)
Special observations (e.g. for effect of the medicines or
tests needed pre-administration)
Observation of the child taking medicines
Preparation and administration of medicines by other
routes:
Midazoam / Oral buccal
Enemas / suppositories
Eye drops
Ear drops
Nasal sprays / inhalers
Nebuliser
Topical creams
Medicines given by the enteral route (where applicable)
Consideration for childs comfort
Discuss any difficulties encountered (e.g. refusal, partial
administration, appropriate administration in difficult
circumstances)

Recognition of the sick child and medicines,

actions to take
82

Area / subject assessed

Assessors comments (discuss areas

of strength and areas for improvement
further learning)

Assessed by
Observation
Questioning
Documentation
Reflection
Discussion

Pass Refer list

actions taken
and review
date

Recognition of pain or distress

Record of drugs given

Signing and checking

Application of knowledge
How to access information on medicines Uses and
purpose of medicines
Relevant to
Usual doses
medicines
Routes of administration
administered in
Adverse effects
the House / for
Side-effects
the child.
Contra-indications
Understanding of as required / prn medicines and
knowledge of guidelines / policy

Allergies
Identification and recording

83

Area / subject assessed

Assessors comments (discuss areas

of strength and areas for improvement
further learning)

Assessed by
Observation
Questioning
Documentation
Reflection
Discussion

Pass Refer list

actions taken
and review
date

Controlled drugs [CDs]

Knowledge of the law, CD Guidelines key issues related
to CDs and relevant medicines.
The role of the Accountable Officer.
Reporting and recording
Condition of the child
When to ask for advice and where to go for this
Dealing with discrepancies
Reporting incidents and near misses, knowledge of
the process and roles and responsibilities
Disposal of medicines
Cleaning and tidying up

Health and Safety in relation to medicines / COSHH

Calculation assessment
To include assessment of the ability to calculate mgs to
mls and knowledge of the critical nature of these
calculations

84

85