CQC Criticised – Have they put patient care at risk?

December 6, 2011

Criticism has been levelled at the Care Quality Commission for apparently putting its registration responsibilities ahead of its duty to inspect hospital trusts and social care providers.

The Pharmaceutical Journal reports today that…

Labour MP Margaret Hodge, chairman of the House of Commons Public Accounts Committee, accused the CQC of “significant failures that [have] put patient care at risk”. She said the organisation — which formed following the merger of three statutory regulators in 2009, and is responsible for regulating nine health profession regulatory bodies, including the General Pharmaceutical Council — is too focused on “box ticking, and not enough on crossing the threshold and assuring quality of care”.

Her comments follow a report on the CQC published last week (2 December 2011) by the National Audit Office, which concludes that the commission is an underfunded organisation chasing to catch up with Government inspection targets.

Between October 2010 and April 2011, the CQC was struggling to meet its inspection obligations and had achieved only 47 per cent of them, the NAO report says. Despite working with a budget smaller than the combined budgets of the organisations it replaced, the CQC also fails to represent value for money, the report adds.

Commission has since taken steps to improve

NAO comptroller and auditor general Amyas Morse welcomed steps the CQC has since taken to improve its service, adding: “Against a backdrop of considerable upheaval, the CQC has had an uphill struggle to carry out its work effectively and has experienced serious difficulties.

“There is a gap between what the public and providers expect and what [the CQC] can achieve. The commission and the Department of Health should make clear what successful regulation of this critical sector would look like.”

CQC chief executive Cynthia Bower said the commission faced a “difficult task” in its infancy, but is now on track to deliver real benefits for people who use health and social care services.

Here’s the report from the National Audit Office

 

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Categories of Medicines

December 5, 2011

Categories of Medicines

Why can you obtain some medicines from a pharmacist, or even buy them from a supermarket, while others can only be obtained with a prescription from your doctor or other healthcare professional?
The difference depends on the level of supervision that experts in medicines consider is needed before you use a particular medicine.
Under laws governing the supply of medicines, there are three categories determining how you obtain medicine:

Prescription-only medicines

(POMs) are available only on a prescription issued by a doctor or other suitably qualified healthcare professional, such as a nurse or pharmacist. You need to see the healthcare professional before they give you a prescription. You’ll then have to take the prescription to a pharmacy or, in rural areas, a dispensing GP surgery for your prescription to be dispensed. Examples of POMs are inhalers to treat asthma or medicines to lower high blood pressure.

Pharmacy (P) medicines

are available from a pharmacy without a prescription, but under the supervision of a pharmacist. You need to ask the pharmacy staff for this type of medicine as it will be kept “behind the counter” and will not be available for you to pick up from the pharmacy shelves. The pharmacist or another member of staff will check that the medicine is appropriate for you and your health problem, and will ask questions to ensure that there’s no reason why you shouldn’t use the medicine. An example of a medicine that you can buy from a pharmacy without a prescription is chloramphenicol eye drops to treat an eye infection.

General sales list (GSL) medicines

can be bought from pharmacies, supermarkets and other retail outlets without the supervision of a pharmacist. These include medicines to treat minor, self-limiting complaints that people may feel aren’t serious enough to see their doctor or pharmacist about, such as the common cold, headaches, other aches and pains, minor cuts and stomach-related upsets.

Can medicines change their status?

New medicines tend to be licensed in the POM category so that healthcare professionals can supervise their use during the first few years they’re available. If a medicine proves safe in large numbers of patients over several years, the regulatory agency may consider changing it from POM to P.
EU regulations encourage switching medicines from POM to P as long as there’s no danger to health if the medicine is used without a prescriber’s supervision and the medicine is unlikely to be used incorrectly.
If a P medicine has shown no problems after several years, it may be considered for a switch to GSL status, so that it can be sold directly from retail outlets.
The UK is currently leading the world in making medicines available over the counter (OTC). A wide range of medicines have switched from both POM to P and P to GSL over the past 20 years, including ibuprofen for pain relief, nicotine replacement therapy (NRT) for stopping smoking, emergency hormone contraception, and clotrimazole and fluconazole for vaginal thrush.
More recently, simvastatin, a medicine that reduces cholesterol as a means of reducing the risk of heart attack, and chloramphenicol eye drops for eye infections have also switched from POM to P.
The government has said that it’s committed to increasing the availability of OTC medicines for common complaints, including treatments for long-term conditions, such as high blood pressure, where it’s safe to do so.
Are medicines I can buy from a pharmacy just as effective and safe?

If a medicine switches from POM to P, or from P to GSL, the active drug remains exactly the same. This means that it’s just as effective as when it had to be prescribed by a qualified prescriber. It also means that there’s the same risk of side effects if you take too high a dose or if you don’t follow the instructions on the label, so it’s important to follow the instructions carefully. Your pharmacist will be able to advise you about any side effects

Completion of Medication Administration Records (MAR’s)

August 6, 2009
Completing medication records

Completing medication records

One of the biggest challenges care organisations have is in ensuring that they have good Medication Administration Records and that their nurses and care staff actually complete them correctly. I recently had the pleasure of the company of a gentleman from the Care Quality Commission who told me that  medication issues are still the greatest area of concern during inspection visits and particularly record keeping. So what are the issues and how can we get it right?

What information should be on a MAR?

The guidance states that a MAR should contain the name and address of the service user, a start date so that I know which record is current or for reference should I need to go an look back at a certain date, the medication details i.e. the name, strength, form, clear dosage instructions and times of day – to state “contents of box” or nomad or dossette etc.is not acceptable, if you have codes for administration then the key for those codes needs to be clearly stated on the MAR, some where for the nurse or carer to either sign or initial, if initials are used there needs to be a master record kept in the office of whose initials tally with which carer or nurse. Any other information on the MAR is not necessary but may make the MAR more robust when in use and so may have quantities received and returned for example, or GP details etc.

Who is responsible for providing the MAR and entering the information?

Legally it is the responsibility of the care organisation to provide the MAR and to put the information on it. Many care homes will have their MAR’s provided by their pharmacy but it actually is a complimentary service to them, pharmacy have no legal or contractual obligation to provide MAR’s at all. There is no official template or recommended format for a MAR and so there are many different types and as long as they meet the requirements above and are filled in correctly it’s what works best for your organisation. The medication information for each client should be entered by the company and any changes to medication should also be made by the care company, written in legibly in ink, if the medication has changed, put a line through the old medication and re-write the new on a new line of the MAR, preferably checked by another person, signed, dated and a note to say on who’s authority was the change made.

Codes for Administration

There are no official codes for administration or guidance given as to what they should be so it is up to the care organisation to decide what information it requires the nurse or carer to record. Good practice would be to have codes for administered, reminded, observed, not taken, refused, dose measured, on leave, in hospital,etc.

Record keeping at the time of administration

Training in how to complete MAR’s is essential if you are to ensure that your teams do it correctly at all times. You should have in place a system to identify where mistakes are being made or records are not being completed properly so that that carer or nurse can be spoken to, given additional guidance and training and standards enforced.

At the time of administration team members must sign or initial the MAR in the appropriate space and an indication of how they supported, this may be by using a code as discussed above. If the person did not require medication the carer or nurse should still sign and add a code to explain that the client didn’t require it. Please do not leave records blank as gaps create questions and uncertainty about what happened at that time. If it was a controlled drug administered by two people both should sign. If it was a variable dose for example “give 10ml or 20ml”  exactly what dose was given should be recorded. If a dose is refused by the service user record that it was refused and why. Any over the counter remedies or homely remedies that you administer should also be detailed on the MAR.

For further information, training on record keeping or examples of good MAR’s you might model contact training@momentumpeople.co.uk or call 01793 700929

Side Effects and Adverse Reactions

April 10, 2008

What are they and what should you do?

Side Effect – An unpleasant effect of a drug that happens in addition to the main effect of that drug.

Adverse Reaction – A negative or harmful effect caused by a medicine

Interaction – When one medicine affects the way that another medicine works in the body, potentially to a harmful effect.

Contra-indication: – A sign that someone should not continue with a particular medicine or treatment because it is or might be harmful.

Side effects and adverse reactions can occur with any medicines. The more medicines a person takes, the more likely it is that an interaction between medicines will occur, making the person unwell. In the section above, some of the side effects of the different types of drugs were listed and whilst it is not expected that you know all the side effects of all the different types of medicines by heart, it is very useful to know the kinds of things to look out for when a service user is given a different medication than he or she normally has.

Common side effects

The most common side effects seen with medicines are:-

  • Nausea
  • Vomiting
  • Diarrheoa
  • Drowsiness
  • Rashes
  • Indigestion/heartburn
  • Headache
  • Constipation
  • Dizziness

If a service user has had a change in medication and you notice that they are unwell or not their usual selves in some way this could be an indication that they are experiencing a side-effect, adverse reaction or interaction with their medication.

What do you do?

  1. Make a note of the symptoms on the medicines administration chart or other service user records.
  2. Report the concern to your line manager
  3. Seek advice from the doctor or pharmacist
  4. If out of hours – call NHS direct
  5. Record the advice given on the medicines administration chart or other service user records.
  6. If the service user becomes seriously unwell you may need to contact the emergency services.

Do not:-

  1. Stop the medication
  2. Give the service user any advice without first seeking advice from a health professional
  3. Do not recommend other medicines to treat the symptoms without first seeking advice from a doctor or pharmacist.

Get the Most from Your Pharmacy Services

April 10, 2008

How much do you know about the services that pharmacies offer which make could make life easier for both you and your service users?

Most pharmacies offer some form of prescription collection and/or delivery service. Many pharmacies will also order the prescription on the patient’s behalf too, they keep the repeat and you let them know what you need – cutting out yet another step of the process for the service user. Ask your pharmacy about repeat medication services.

As well as prescription services, the pharmacy, under it’s new Pharmacy Contract, is able to offer a range of other services which you, or your service users might find particularly useful.

Compliance Aids and the DDA

One of these services is the provision of compliance aids under the Disability Discrimination Act (DDA). Under new contract, the pharmacy is required to carry out an assessment with any service user who requests a compliance aid. This assessment helps to ascertain whether the service user is disabled and therefore qualifies for free support in the form of compliance aids.

Compliance aids, as we discussed in unit 1 of this course include the following:-

· Dosette or similar boxes

· Non-child proof tops

· Large print labels

· Braille labels

· Talking labels

· Provision of medication administration record charts

· Colour coding of labels to time of day

The purpose is to enable the service user the necessary support to get the most from their medicines and remain as independent as possible.

Medicines Use Reviews

A medicines use review is an appointment with a pharmacist to focus on how the an individual is getting on with their medicines. It usually takes place in the local pharmacy, but with permission from the Primary Care Trust, may take place in a service user’s home. It is an NHS service – and is free to the service user.

The meeting is to:

· Help the service user to find out more about the medicines

they are taking.

· Pick up any problems they are having with their medicines.

· Improve the effectiveness of their medicines.

· There may be easier ways to take them, or the service user may find that they need fewer medicines than before.

· Get better value for the NHS – making sure that the medicines are right for the individual to prevent unnecessary waste.

The pharmacist will have questions and may suggest changes to the

medicines. The service user may have concerns or questions that they want to ask about.

A medicine user review can be requested by ay the service user or any health professional or carer as long as the service user gives their consent.

Repeat Dispensing

Under the new contract you don’t have to go back to the doctor every time you need to renew a prescription. Instead, your doctor can give a prescription lasting up to a year and the pharmacist can dispense the medicines as and when they are needed. This service is called “Repeat Dispensing” and is available to patients who are stable on long term medication. More and more pharmacies and surgeries are offering this service and it may well be worth asking about.

Public Health Advice

In order to help reduce health inequalities and improve health the pharmacist can give you and your service users clinical and lifestyle advice on how to become healthier. This includes advice and information on how to stop smoking, reducing high blood pressure, lose weight and improve your diet. This will help to proactively tackle national diseases such as obesity, coronary heart disease and cancer. Pharmacies will be taking part in local and national health promotion campaigns

Signposting

If you have a health problem and are not sure where you should go to get advice or treatment, your pharmacist can help put you in touch with the appropriate service.

Self Care

Your pharmacist is be able to advise on which over the counter medicines are best for self-limiting conditions as well as give help on other things you could do to help you or your service user feel better.

Top 5 Myths about Compliance Aids in Social Care Dispelled

March 6, 2008

j0390523.jpg  Compliance aids are used extensively in social care and I would like to take this opportunity to clear up a few myths about them if I may.

Myth #1

In order to support a service user with his or her medication it must be in a monitored dosage system (MDS)

This is incorrect. There is absolutely no legal or ethical reason why medication needs to be in a monitored dosage system. It can just as easily and safely be supported from bottles, boxes and original packs as long as the correct checks are made, the dose instructions followed and good records kept. Incidentally these things have to happen for MDS too.

Myth #2

All tablets and capsules can be put into a MDS

This is incorrect. Not all tablets and capsules will remain stable once out of their original packaging and therefore must be dispensed in their original packs.

Myth #3

You can legally support a service user who has their medication put into the MDS by a friend or relative

This is incorrect. All monitored dosage systems must be filled by a pharmacist (or dispensing GP in rural areas). Supporting medication in trays filled by friends or relatives is not legal. If this is happening in your service you should take steps to make changes. Inform relatives or friends that from a certain date (e.g. a month’s time) that you will no longer be able to support the service user if they continue to fill the trays themselves. They should go to the pharmacy and request an assessment under the Disability Discrimination Act in order to have the medication dispensed by the pharmacy into a suitable MDS. If the service user meets the criteria of the Disability Discrimination Act they will be entitled to this service free of charge from the pharmacy.

Myth #4

All MDS systems are appropriate for use in social care.

This is incorrect. Any MDS system used in both care homes and domiciliary care must be dispensed by the pharmacy into a system that is able to be properly labelled to identify it’s contents on the actual pack containing the medication. The system used should also be tamper evident and secure.

Any system that does not meet this requirement should not be dispensed into by the pharmacy for use in social care. This includes the little “finger” type systems that have a different “finger” per day that can be taken separately from the pack. These systems have historically been purchased by the service user and filled by the pharmacy which is fine if they are assessed and unsupported, for you though as care staff supporting service users they are not suitable. If you have clients using these systems please ask the pharmacy to provide a system that meets labelling and security requirements.

Myth #5

The pharmacy dispensed the medication into the tray and therefore it’s nothing to do with me, not my responsibility to make any checks.

This is not correct. You have a legal obligation to check that the right patient receives the right medicine by the right route in the right dose at the right times. So, you then need to check the name on the pack is the right service user. You need to check that the contents of the pack match both what was ordered on the prescription and what is on the medication administration record. You need to check that the strength of the medication is what was expected and that the instructions for use are the same. Do the time slots in the pack match the administration times and do you know exactly how this medication is to taken, used or applied?

I do hope that this has cleared up many common misperceptions about monitored dosage systems and that as a result you will check your policies and procedures and update where necessary.

If you have any further questions about compliance aids or would like support in writing or reviewing polices please contact:-

Tracey Dowe

Email training@momentumpeople.co.uk

Tel 01793 700929

http://www.momentumpeople.co.uk

Consent and Medicines Management

March 6, 2008


Forms Before any support with medication can happen in care the service user must give their consent. In order to give informed consent they must first be given all of the information they require to make a decision about their level of care. It is important that information is shared freely with the service user, this will include providing patient information leaflets to your service users, and if necessary reading and explaining these to them if they are not able to do this themselves.

A service user can agree to treatment and care verbally, in writing or by implying (by co-operating) that they agree. Even though verbal consent or consent by implication would be enough evidence in most cases written consent is always preferable and probably expected in most care agency policies.

Service user consent should be obtained and recorded in the care plan during the care assessment. Both the service user and the assessor should sign and date the document. Written consent stands as a record that discussions have taken place and of the service users choice. however, the service user had the right to refuse consent and may do so at any time during his or her care. This may be detrimental to their care and you must provide them with the information they require to be fully informed I making their decision but if they still refuse to consent then you must respect that decision. You should make a record of the refusal and document what information was given and who else you involved such as your line manager or GP in the service users records.

What you should never do is hide the medication in food or beverages for the service user to take without knowing that it is there. This is covert administration of medicines and is considered to be abuse.

In an emergency situation were treatment is necessary to preserve life and the service user cannot make a decision (for example because they are unconscious), the law allows you to provide treatment without their consent, providing you are sure you are always acting in their best interest.

You should also know that if the service user is an adult, consent from relatives is not sufficient on its own to protect you in the event of a challenge, as nobody has the right to give consent on behalf of another adult unless the service user has passed over the power of attorney to another person. In this case the other person can give their consent for you to administer medication

As you can see gaining consent may not be as straightforward as it first appears. Nonetheless, it is a vital part of caring for people. The reason it is so important is that it is assumed that the service user is the best person to be in control of their care. So any procedure that may affect them can only be given once they have consented to the care and this includes medication.

 

For further information Contact

Tracey Dowe

email training@momentumpeople.co.uk

Tel 01793 700929

http://www.momentumpeople.co.uk

Covert Administration of Medicines

January 7, 2008

j0321104.jpg    Covert administration of medicines has recently hit the news again and in my training I often meet care workers who do not understand what covert administration is and why it is not acceptable. ‘Covert’ administration of medication is disguising the medicine in food, normally by crushing tablets or opening capsules and mixing them with the food to be eaten by the service user and they do not know they are taking it.

Care workers who have not been trained on medicines management will often think they are acting in the best interest of the service use, rationalizing that it is better that the person gets the medication than go with out because they do not want to take it. On the surface it appears a reasonable thing to do to them.

However, by law consent must be obtained from service users before any treatment or care or help with taking their medicines is given to them. Their decision, whether or not to agree to treatment or care has to be based on adequate information so they can make up their own mind what level of support is appropriate for them.

In theory a service user can agree to treatment and care verbally, in writing or by implying (by co-operating) that they agree. Equally a service user may take away that consent in the same way. Even though verbal consent or consent by implication would be enough evidence in my book nothing beats written consent, it’s always preferable and probably expected in most care agency policies.

Such consent should be recorded in the care plan and the service users signature obtained on the care plan during the care assessment. Written consent stands as a record that discussions have taken place and of the service users choice.

In the context of medication you need to be aware of how consent is managed. You are likely to need the service user to sign for their medication administration; this may be done once at the care assessment stage, each week/month as a new medication administration record is used or each

It is important that information is shared freely with the service user, in an accessible way and in appropriate circumstances. This includes providing patient information leaflets to your service users, and if necessary reading and explaining these to them if they are not able to do this themselves.

In an emergency situation were treatment is necessary to preserve life and the service user cannot make a decision (for example because they are unconscious), the law allows you to provide treatment without their consent, providing you are sure you are always acting in their best interest.

You should also know that if the service user is an adult, consent from relatives is not sufficient on its own to protect you in the event of a challenge, as nobody has the right to give consent on behalf of another adult unless the service user has passed over the power of attorney to another person. In this case the other person can give their consent for you to administer medication

Legally, a competent adult service user can either give or refuse support, even if refusal will be to their detriment. However, you must respect the refusal of consent by a service user just as much as you would their consent. You must make sure that service user has been fully informed and, when necessary, involve another member of the health and social care team. You should make sure that a summary of any such discussion and the decision is documented in the service users records.

Consent to support with the administration of medicines means there must never be any ‘covert’ administration of medication e.g. disguising the medicine in food (unless someone is mentally incapacitated and a multi-disciplinary team deems this to be in the service users best interest).

It is important that the principles governing consent are applied just as vigorously to all forms of care with people who are mentally incapacitated as with a competent adult. When a service user is considered incapable of providing consent, or where the wishes of a mentally incapacitated service user appear contrary to the interests of that person, you may need to involve other people close to them, but respect any previous instructions the service user gave. Covert administration is still a last resort and can only be authorized by a multi-disciplinary team of health professionals.

As you can see gaining consent may not be as straightforward as it first appears. Nonetheless, it is a vital part of caring for people. The reason it is so important is that it is assumed that the service user is the best person to be in control of their care. So any procedure that may affect them can only be given once they have consented to the care and this includes medication.

Prompting Vs Administration of medicines…..

December 17, 2007

j0178847.jpgA topic close to many of our hearts if we are in the business of caring for people who take or use any form of medication. It’s a mine field isn’t it? If you or your care staff were administering medicines to your service users – you would want to ensure that they were fully trained and competent to do so wouldn’t you? Me too.

Supporting people in taking their medication is all a bit scary. What if you get it wrong? The results could be disastrous and therefore many agencies prefer to think they are acting on the safe side by not getting involved in medicines administration at all.

As a result care organisations are still not training their carers in this vitally important area of care. Why? Because they are under the misperception that because they only prompt the administration of medicines, and do not (in their eyes) administer it, they therefore do not need to go to the trouble or expense of training their team.

BUT – did you know that in the eyes of the law Administration means to both personally administer AND to prompt the administration of medicines?

Therefore, if you are prompting medication you are actually administering it, there is no difference in the eyes of the law. The same checks need to be in place, the same record keeping needs to be completed, the same level of knowledge is required to fully support the client – even if you only prompt from a monitored dosage system. The monitored dosage system must be prepared by the pharmacy or a dispensing doctor for you to legally prompt or administer from it and whilst they have a responsibility to ensure that it leaves the pharmacy with the correct medication inside, you still have the responsibility to ensure that the right person gets the right dose of the right medicines by the right route at the right time.

So – if you are supporting service users who use medication you must ensure that you give your care workers the best possible training, relevant to your sector of care, that meets CSCI and Skills for Care requirements in order to safe guard your clients, your care workers and your business.

For further information about administration vs prompting or training requirements contact Tracey Dowe at Momentum People Ltd on 01793 700929 or email training@momentumpeople.com

Secondary Dispensing – Still an Issue in Care

December 13, 2007


j0390523.jpg

This is an issue that I came across recently whilst delivering training in medicines management to a domiciliary care.  I was surprised to hear how much it still happens out there and feel that it’s an area that needs to be highlighted and discussed – put out in the open if you like.

What is secondary dispensing?

Let me give you an example.

You have service users who visit a day centre and will be there for there lunch time medication. The medication is dispensed by the pharmacy into a monitored dosage system which you feel is a bit big for the service user to take to the day care centre with him or her so you take out the lunch time doses and put them into an envelope with their name on it for him/her to take with them.

Or

You have a service user who goes home occasionally for the weekend. You don’t want to send the whole cassette with their medication in with them, perhaps you’re not sure it will be returned when they come back, so you put the weekend medication in to another container with their name on it and brief instructions as to when they should be taken.

What’s wrong with that you might say?

The issue is that you are not qualified to dispense medication. You are giving out medicines that are not labelled properly or legally and the medication is not identifiable in any way. It also does not give the service user proper dose instructions or warning instructions or safe storage instructions. By giving someone medication in this way you are taking responsibility for it, if some thing goes wrong you are liable because you acted outside of the law.

So that’s all very well you say – but what is the solution? How do you ensure that the service user gets the medication at the day centre or during home visits?

There are two possible solutions. The first is to send the service user with the medication in the original pack, be that the boxes and bottles dispensed by the pharmacy or the monitored dosage box (e.g. nomad tray, blister pack, dosette).
If your policies do not allow this to happen at present, then in order to operate with in the law perhaps it is time to review those policies.

The second option is to speak with the GP practice and the pharmacy to arrange to have the doses needed for outside your care dispensed in to separate containers that the service user can take with them. The medication must be dispensed by either a pharmacy or a dispensing doctor though, not by your staff.

But we’ve been doing this for years you cry! Yes…I know but it doesn’t make it right.

But our inspectors have never said anything about it you tell me……yes…..but perhaps as knowledgeable as they are they are in legislation and guidelines they are not experts in medicines and do not know that what you’re doing is not legal. When something goes wrong ignorance will not be a defence so better to put things right as soon as possible rather than hoe it will be ok and continue to break the law.

For further information or any questions about this or any other medication issues please contact tracey.dowe@momentumpeople.co.uk