Medication

Training and Guidelines For Care Staff (adult care)

Introduction

This training pack is for Comhairle Nan Eilean Siar (CNES) care staff who work with adults (over 16 years of
age)
in the following settings:

• Residential and day care services
• People in their own homes.

It covers the administration of medicines to adults, including those with learning disabilities. It
is not intended to cover administration of medicines to children.
All care staff will be required to complete this training pack and assessment before they can
assist with or administer any medicines. In addition, the staff member’s manager will have to
be satisfied that the staff member is competent and confident in this task.
Care staff should complete this training pack as part of their induction. It is the intention that
all staff involved in assisting with or managing medicines will go on to complete further
training to at least Scottish Vocational Qualification (SVQ) level 2 but ideally to SVQ level 3,
or equivalent.
In addition to this training pack, staff should be familiar with the following CNES
policies, relevant to their area of work:

• Policy on the Role of Care at Home staff in the Management of Medicines
• Medicines Management in Adult Residential and Day Care Services Policy

WHAT ARE MEDICINES?

Definition of a medicine
For the purpose of this training pack, a medicine is considered as a substance which people
take or use to benefit their health. For example, a medicine may be used to: prevent a
medical condition happening or getting worse, relieve symptoms or treat a medical condition.
Medicines come in many different formulations and not just those that are swallowed e.g.
tablets and capsules. Medicines can also be applied to the skin, inhaled into the lungs, or
injected. There are more examples later in this pack.
Most medicines that care staff will assist with or administer will be prescribed for people. It is
not only medicines that are prescribed. Often, people will have other items prescribed for
them, for example:

• Wound dressings
• Oxygen therapy
• Incontinence appliances such as catheters and leg bags
• Foods and food supplements
• Stoma appliances

Classes of medicine

There are three classes of medicines:

1. General sales list (GSL) – these are medicines that can be purchased in small
   quantities in pharmacies, shops, supermarkets and garages.
2. Pharmacy medicines (P) – these are medicines that can only be sold or supplied
   under the supervision of a pharmacist. This is so that the pharmacist can check if
   there is a reason why the person should not take the medicine or if there is the
   possibility with an interaction with other medicines that may be being taken.
3. Prescription only medicines (POM) – these are medicines that can only be supplied
   on the direction of an appropriate prescriber. In most cases a prescriber will have to
   write a prescription for these medicines. Prescribers are traditionally doctors or
   dentists but some nurses, pharmacists and other professionals can now prescribe
   too.

Some medicines have additional controls on who can supply, dispense or possess them –
these are called controlled drugs.

Generic and brand names

Many medicines have two different names – the generic name and the brand name.

The generic name is the active ingredient in the medicine. The brand name is the name
given to the medicine product by the manufacturer. Some examples of generic and brand
names are:

In most cases it will be the generic name that appears on the medicine label but the
manufacturer’s container will have the brand name of the medicine.

Forms of medicines

There are many different forms of medicines. The form indicates the route by which the
medicine is administered. Some examples are given in the table below.

Note that not all forms of medicines listed should be administered by care staff without
further training.

Dispensing Label

When a medicine is prescribed for a person, it is usually dispensed/supplied by a community
pharmacy or a hospital. In locations without a pharmacy, the local GP practice may dispense
medicines (but not all GP practices can do this).

When a medicine is dispensed, a dispensing label is attached. The label indicates who the
medicine is for and gives information about the medicine. The following information must be
on a dispensing label:
•The name of the person the medicine is prescribed for
•The date on which the medicine was dispensed
•The name, strength and form of the medicine
•The quantity of medicine
•The directions or instructions for using the medicine
•Any special warnings
•The name, address and telephone number of the pharmacy (or dispensing GP
practice)

An example of a dispensing label is given below.

Cautionary and advisory labels

Medicines may have cautionary or advisory warnings that appear on the label. It is important
that you read the cautionary or advisory warnings when helping people with their medicines
or administering medicines to people.

Cautionary or advisory warning labels give information about:
•Side effects that might happen
•How the medicine should be taken or used
•When the medicine should be taken
•Other medicines to avoid

Some common ones are:

•Warning: This medicine may make you sleepy. If this happens, do not drive or use
tools or machines. Do not drink alcohol
•Warning: Do not stop taking this medicine unless your doctor tells you to stop
•Warning: Read the additional information given with this medicine
•Take with or just after food, or a meal
•Take 30 to 60 minutes before food
•Swallow this medicine whole. Do not chew or crush

‘When required’ medicines

Some medicines are only required on a “when required” rather than regular basis. Examples
include pain killers and laxatives.

The dispensing label will state if a medicine is being prescribed “when required”.
People who are having their medicines managed for them (ie, administered) may also have
a form that accompanies their medication record or MAR Chart which gives further details
about how “when required” medicines should be administered. This includes how often the
medicine can be given, the maximum safe dose and the criteria for giving the medicine.

Further information on assisting with or administering “when required” medicines is provided
in the training for different care settings.

PRINCIPLES OF MEDICINES ADMINISTRATION AND ASSISTANCE

Authorisation to administer medicines

In the UK, anyone can assist with or administer a medicine that has been prescribed. This
administration must be in accordance with the directions on the prescription.

When a medicine is prescribed on an NHS prescription form, this gives care staff the
authorisation to assist with or administer a medicine.

In most care services, a chart is used to record the administration of medicines by care staff.
This chart is called a MAR (Medicines Administration Record) chart. MAR charts are NOT
prescriptions but the information they contain comes from the person’s prescription.

There should be systems in place in the service in which you work to ensure that the
information on a MAR chart is the same as that on the prescription, and that any changes to
what has been prescribed are updated on MAR charts.

Assisting or administering – what’s the difference?

Whenever possible, people should be encouraged to manage their own medicines and to
take/use their own medicines themselves. However, not everybody can do this. There are
two levels of support provided.

The first level of support is providing assistance with medicines – this is known as “assisted
support”.

The second level involves care staff providing a greater degree of support by administering
the medicines – this is termed “managed support”.

The differences between these two levels of support are explained below.

Assisted support

Under the “assisted” level of support, the person always retains responsibility and capacity
for their own medicines. The person makes an active choice about what medicines to take
and when to take them but may require assistance to do so because of:

(a) Reduced physical capacity
(b) Forgetfulness/memory impairment

The role of care staff is to provide assistance but not to take any decisions.

People with a degree of forgetfulness/memory impairment may only require assisted support
if they still have the capacity to make decisions about their medicines. The assistance they
require is a simple prompt to remind them to take their medicine e.g. telling the person the
time, reminding the person that they need to take their medicines and asking if medicines
have already been taken. In this situation it is essential that the person is monitored closely
and that any changes to capacity are documented and discussed with senior care staff and
relevant clinical staff.

The types of tasks included in assisted support are:

•Ordering and collecting prescriptions from the GP practice. The person should be
able to tell care staff what medicines need to be ordered.
•Collecting medicines from a community pharmacy/dispensing GP practice. This may
not be necessary if the pharmacy provides a delivery service.
•Helping the person to safely and securely store their medicines. In residential care
services a suitable, lockable storage cabinet should be made available for the
safekeeping of the person’s medicines. The person will be responsible for the key to
their cabinet.
•Arranging a review of medication for the person with their GP.
•Prompting/reminding people to take their medication e.g. telling the person the time,
reminding the person that they need to take their medicines and asking if medicines
have already been taken. This should not need to involve care staff
reminding/checking which medicines need to be taken/have been taken.
•Reading labels on medicine containers.
•Opening containers, medicine bottles, removing tablets from strips. Assistance with
Monitored Dosage Systems (MDS) or compliance aids (blister packs) can only be
given if these have been dispensed by a community pharmacy/dispensing GP
practice. Staff should not fill MDS or compliance aids.
•Removing medicines from packaging and giving them to the person to take, rather
than being administered by care staff. If the person requires the medicine to be
placed into their mouth by care staff this should be on clear instruction from the
person.
•Assisting with the application or use of a medicine (e.g. creams, eye drops, ear drops
or nasal spray) where the person cannot physically apply/use it themselves. The
person should be able to instruct care staff on the application/use of the medicine.
Note that some medicines require additional skills to apply/use and so are not
included in assisted support. The member of care staff should be trained in how to
apply/use such medicines.
•Purchasing over-the-counter medicines at the person’s request. Purchases should
ideally be made at the person’s regular community pharmacy where a check can be
made of how safe and suitable they are for the person against their repeat
medication record. In remote areas without a community pharmacy, advice should be
sought from the person’s GP before purchasing medicines from a retail outlet.
•Disposing of medicines by returning them to a community pharmacy/dispensing GP
practice. The person must be able to tell care staff which medicines to return for
destruction.

Managed support

Under the “managed” level of support, the person is assessed as being unable to manage
his/her medicines. People receiving this level of support require full assistance to ensure
they receive the medicines they are prescribed. The person or their representative must
agree to this level of assistance being given.

The types of tasks included as part of managed support are:

•Ordering and collecting prescriptions from the GP practice. Care staff will be required
to determine which medicines need to be ordered.
•Collecting medicines from a community pharmacy/dispensing GP practice. This may
not be necessary if the pharmacy provides a delivery service.
•Safely and securely storing medicines for the person. Such medicines are normally
stored centrally within the care service and individuals will not have access to the
majority or all of their own medicines.
•Arranging a review of medication for the person with their GP.
•Administering medicines. This involves care staff identifying which medicines need to
be administered from the person’s medication record/MAR chart, selecting the
correct medicine from its packaging and administering the medicine to the person.
•Applying medicines e.g. creams, eye drops, ear drops or nasal spray. The member of
care staff should be trained in how to apply/use such medicines. Note that some
medicines require specialist skills to apply/use and so are not included in managed
support.
•Disposing of medicines by returning them to a community pharmacy/dispensing GP
practice. Care staff are responsible for determining which medicines to return for
destruction.

Who decides what level of support is required?

People should always have been assessed to determine if they need assisted or managed
support with their medicines. Part of this assessment will also look at whether the person
has the mental capacity to make decisions about their own health and treatments. Adults are
presumed to have capacity unless there is good evidence that they do not.

If it is thought that a person lacks capacity to manage their own medicines and to consent to
having their medicines managed for them, then they should be assessed to determine if this
is the case. This assessment is normally carried out by the person’s GP and a certificate of
incapacity issued if necessary.

If you are providing a person with assisted support and you think they are not managing then
you should speak to a senior member of care staff to raise concerns.

Which medicines can care staff administer?

Care staff can assist with or administer the following types of medicines:

•Oral medicines including tablets, capsules, dispersible tablets/capsules and
buccal/sublingual tablets
•Oral liquid medicines
•Creams, ointments and lotions
•Eye drops and ointments
•Ear drops and ointments
•Nasal drops and ointments
•Skin patches
•Inhalation devices
•Mouthwashes

In some cases, care staff who have received additional training can also assist with or
administer other forms of medicines, for example:

•Administration of oxygen
•Administration of medicines using a nebuliser
•Insertion of pessaries
•Insertion of suppositories or microenemas
•Changing simple dressings

If you are unsure of whether you should be assisting with or administering a particular
type of medicine then you should always check with someone senior.

If you are at all unsure of how a medicine should be taken or used, always check first.

Medicines to be administered by a health professional

Some medicines must always be administered by a healthcare professional. These
medicines cannot, even with additional training, be administered by a member of care staff.
It is normally community nurses who administer these medicines in the person’s own home
or care home. They can also be administered by a practice nurse if the person is well
enough to visit the GP practice. These medicines and associated tasks are:

•Injections, including vaccinations and intravenous antibiotics
•Removal of stitches
•Insertion of catheters
•Stoma care in post-operative phase when routine clinical assessment is still
necessary
•Complex wound management procedures and dressing changes including packing of
wounds, multi-layer bandaging and negative pressure wound therapy
•Sodium chloride flush via (Peripherally Inserted Central Catheter) PICC line
•Subcutaneous fluids
•Administration of medicines using syringe drivers
•Administration of products where the initial needs assessment says a health
professional needs to be involved
•Administration of medicines which need skilled observations either before or after
administration.

The following tasks are normally considered to require health professional input. In some
circumstances these tasks may become managed support providing care staff have
undergone additional training. They include:

•Insertion of pessaries
•Insertion of suppositories,microenemas or other medicines administered rectally
•Administration of medicines using a nebuliser
•Changing some types of dressings (eg, simple dry dressings)
•Changing catheter leg bags where this not disturb the catheter
•Changing colostomy bags
•PEG (percutaneous enteral gastrostrostmy) feeding where there is no disturbance to
the catheter
•Administration of medicines via a PEG tube where specific written directions from the
prescriber are available
•Naso-gastric tube feeding
•Administration of medicines via a naso-gastric tube where specific written directions
from the prescriber are available
•Administration of emergency rescue medication e.g. for patients with epilepsy
•Testing for diabetes (blood glucose by finger prick).

Monitored dosage systems (MDS)

Monitored dosage systems (MDS) are a form of medicines compliance aid. They are
sometimes called Dosette® boxes or blister packs (see picture).

Some people who receive the “assisted” level of support may have their medicines
dispensed in an MDS. MDS are not used for people requiring “managed” support.

Care staff should only assist people with MDS that have been prepared by a community
pharmacy/dispensing GP practice. They should never assist anyone with a MDS that has
been prepared by a carer, relative, friend or the person themselves.

Care staff must never fill a MDS for a person. The reason for this is that there are a
number of safety concerns with the use of MDS:

•Not all medicines are appropriate for use in a MDS e.g. tablets/capsules that are
sensitive to moisture.
•The effectiveness of a medicine can no longer be guaranteed under the product
licence when it is removed from its original packaging.
•Only professionals with appropriate training (e.g. pharmacists) can safely dispense a
MDS

MDS may be useful for people receiving assisted support in the following situations:

•A person has difficulty accessing medicines from their original packaging (but note
that MDS can present similar difficulties).
•A person has difficulty following a medication regime due to factors such as:
o The complexity of the regime as a result of the number of medicines to be
taken and/or the frequency that medicines have to be taken
o Sight impairment
o Confusion
o Some situations of forgetfulness
o Learning difficulties

MDS are inappropriate for:
• When they are provided solely for the benefit of care staff
• When people are no longer able to manage their own medicines
• People with intentional non-adherence to medicines or poor motivation
• People who have difficulty accessing a MDS because of problems with dexterity or
cognitive impairment
• People who have frequent changes to their medicines

HOW TO ADMINISTER MEDICINES

This section of the training involves a practical workshop on the administration of medicines.
The notes summaries the practical advice provided at the workshop.

The five “rights”

A good way to ensure that a medicine is administered as intended is to think about the “FIVE
Rs” or “FIVE RIGHTS” every time. These are:

•RIGHT medicine
•RIGHT person
•RIGHT time
•RIGHT dose
•RIGHT route

In other words, you need to check you are giving the RIGHT medicine to the RIGHT person
at the RIGHT time at the RIGHT dose and via the RIGHT route.

Before you begin…

EVERY time you assist a person with his/her medicines or administer medicines, you should
follow these steps:

Get prepared

• Wash your hands
• Make sure you have a clean and tidy area in which to work
• Ask if the person wants to take their medicines
• Explain to the person what you are going to do and what is going to happen
• If the person is going to be swallowing a medicine, make sure they are in a
• comfortable and upright position and has a glass of water available to help them
• swallow the medicine.
• Make sure you have the right documentation and the right medicines – does the
  person’s name on the paperwork match that on the labels on the medicines and are
  they for the right person?
• Make sure the medicines haven’t been given already – check the medication
  record/MAR chart or, if appropriate, check with the person and/or their carer.

For people requiring “assisted” support

1. People requiring “assisted” support should know themselves what medicines to take
   and when to take them.
2. Provide the assistance the person requires, eg, opening packaging, measuring
   liquids, reading labels, prompting person.
3. Record the assistance provided.

For people requiring “managed” support

1. From the person’s medication record or MAR chart, determine what medicines need
   to be given at this time.
2. Compare the information on the medication record/MAR chart with the information on
   the medicine label, checking:
   a. The person’s name
   b. The name of the medicine
   c. The dose to be administered
   d. The time of administration
   e. Any cautionary/advisory labels such as timing of administration in relation to
   meals.
3. Check the expiry date of the medicine.
4. Administer the medicines.
5. Record the medicines administered.

If there are any discrepancies between the information on the medication
record/MAR chart and the information on the medicine label then advice from a
senior needs to be sought.

Administering different forms of medicines

The following sections give information and instructions on how different forms of medicines
should be taken or used.

Oral tablets and capsules
Tablets and capsules come in a variety of shapes, sizes, colours and types.

Tablets and capsules should not be crushed or split unless it is stated on the dispensing
label and/or MAR chart that this can and should be done. Some tablets/capsules must
always be swallowed whole and not chewed or crushed. These tablets/capsules tend to be
called “sustained-release”, “controlled-release” or “modified release”. They will have an
advisory label stating: “Swallow this medicine whole. Do not chew or crush”.

Advice on whether tablets can be crushed or capsules opened can be given by a community
pharmacist/dispensing GP.

• Prepare a drink of cold water – at least half a tumbler full.
• Transfer the correct number of tablets/capsules into a clean container, such as a
  measuring cup, without touching them with your hands. If the tablets/capsules come
  in a blister strip, pop them directly into the container. If the tablets/capsules come in a
  bottle, shake the correct number into the lid of the bottle before transferring to the
  clean container.
• Ensure that the person is a comfortable upright position, as far as possible.
• Ask the person to take a sip of water or help them to do this.
• Depending on the person’s abilities, either hand the clean container to the person for
  him/her to place the tablets/capsules on the middle of the tongue, or place the
  tablets/capsules on the middle of the person’s tongue.
• Ask the person to swallow the tablets/capsules with a drink of water, keeping the chin
  slightly down.
• Ensure that all the tablets/capsules have been swallowed.
• Encourage the person to finish the water to make sure that the tablets/capsules have
  been washed down.

Chewable tablets, lozenges and pastilles

Some tablets are meant to be chewed. These will they will have an advisory label stating:
“Suck or chew this medicine”. Lozenges and pastilles should be sucked.

• Transfer the correct number of tablets/lozenges/pastilles into a clean container, such
  as a measuring cup, without touching them with your hands. If the tablets/lozenges/
  pastilles come in a bottle, shake the correct number into the lid of the bottle before
  transferring to the clean container.
• Ensure that the person is a comfortable upright position, as far as possible.
• Ask the person to take a sip of water or help them to do this.
• Depending on the person’s abilities, either hand the clean container to the person for
  him/her to place the tablets/lozenges/pastilles in the mouth or place the tablets/
  lozenges/pastilles into the person’s mouth.
• Ask the person to suck or chew the tablets/lozenges/pastilles.
• Ensure that the tablets/lozenges/pastilles have been sucked or chewed completely
  and that none remains in the mouth.

Soluble or dispersible tablets and capsules

• Prepare a drink of cold water – at least half a tumbler full.
• Transfer the correct number of tablets/capsules into the water without touching them
  with your hands.
• Allow the tablets/capsules to dissolve completely.
• Ensure that the person is a comfortable upright position, as far as possible.
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• Swirl the tumbler gently in order to ensure adequate mixing of the medicine in the
  water.
• Hand the tumbler to the person or help him/her to drink the liquid.
• Ensure the person drinks all of the liquid.
• Offer the person another drink afterwards.

Sublingual tablets

• Transfer the correct number of tablets into a clean container, such as a measuring
  cup, without touching them with your hands.
• Hand the clean container to the person to place the tablet under his/her tongue or
  place the tablet under the person’s tongue.
• Remind the person to leave the tablet under the tongue and to allow it to dissolve but
  not to chew or swallow the tablet.
• Ensure the tablet has completely dissolved.

Buccal tablets

• Transfer the correct number of tablets into a clean container, such as a measuring
  cup, without touching them with your hands.
• Hand the clean container to the person for them to place the tablet high up between
  the upper lip and gum on either side of the front teeth or place the tablet for the
  person (see picture).
• Remind the person to leave the tablet between the upper lip and gum but not to chew
  or swallow the tablet.
• Ensure the tablet has completely dissolved.

Oral liquids

Only one bottle of medicine should be in use at any one time. If the person has more than
one bottle of the same medicine open, finish one bottle before opening another. Liquid
medicines should not be mixed or added to water unless specified by the instructions.

• Shake the bottle to mix the liquid, ensuring the bottle top is on tightly.
• Using either a 5ml medicine spoon, a measuring cup or an oral syringe, measure out
  the correct dose.
• Offer the spoon, measuring cup or syringe to the person.
• Help the person to swallow the liquid.
• If using an oral syringe, slowly expel the liquid onto the middle of the person’s tongue
  or into the side of the mouth. Never squirt the liquid into the throat.
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• Clean the neck of the bottle and any drips with a clean damp cloth before replacing
  the bottle top

Topical formulations – creams and ointments

• Wear disposable gloves.
• Transfer the quantity of cream/ointment required onto the finger of your glove.
• Apply the cream/ointment only to the affected part of skin, spreading thinly and using
  the smallest quantity that will rub easily into the skin.
• Gently rub the cream/ointment into the skin. The person may be able to do this.
• Replace the cap on the tube/tub and dispose of the disposable gloves.
• If the person has rubbed in the cream/ointment, ensure his/her hands are washed too
  (unless the area being treated is the hands).

Topical formulations – lotions

• Wear disposable gloves.
• Transfer the quantity of lotion required onto a clean piece of gauze.
• Apply the lotion only to the affected part of skin, spreading thinly and using the
  smallest quantity that will rub easily into the skin.
• Gently rub the lotion into the skin. The person may be able to do this.
• Replace the cap on the tube/tub and dispose of the disposable gloves and piece of
  gauze.
• If the person has rubbed in the lotion, ensure his/her hands are washed (unless the
  area being treated is the hands).

Eye drops and ointments

Once opened, bottles and tubes of eye drops and ointments have a shelf life of 28 days and
should be discarded after then.

• Tilt the person’s head back and ensure it is well supported.
• Gently pull down the person’s lower eye lid.
• Bring the nozzle of the bottle/tube close to the eye and ask the person to look up.
• For drops, gently squeeze the bottle allowing the prescribed number of drops to be
• placed inside the lower lid.
• For ointment, gently squeeze the tube drawing a line of ointment along the inner edge of the lower lid from the nose outwards.
• Ask the person to close the eye.
• Wipe away any excess drops/ointment with clean cotton wool.
• Replace the cap on the bottle immediately after use.

Ear drops and ointments

• Tilt the person’s head to the side or ask the person to lie down on their side so that
  the ear to be treated is uppermost. Ensure the person’s head is supported.
• Gently squeezing the bottle, place the prescribed number of drops into the ear,
  allowing the drops to fall in the direction of the ear canal.
• Keep the person’s head tilted for one or two minutes.
• Replace the cap on the bottle immediately after use.

Nose drops

• Ask the person to blow their nose or help the person to clean the nasal passages
  with a tissue.
• Tilt the person’s head back, with the neck being supported.
• Ask the person to breathe through their mouth and, gently squeezing the bottle, place
  the prescribed number of drops into the nose. Avoid touching the nose with the bottle
  when doing this as it can cause the person to sneeze.
• Ask the person to keep their head tilted back for one or two minutes.
• Replace the cap on the bottle immediately after use.
• The person may complain that they can taste the drops. This is normal and nothing
  to be concerned about.

Nasal cream or ointment

• Wear disposable gloves.
• Transfer the quantity of cream/ointment required onto the finger of your glove.
• Apply the cream/ointment only to the inside of the nostril, smearing it round the
  nostril. The person may be able to do this.
• Replace the cap on the tube and dispose of the disposable gloves.
• If the person has rubbed in the cream/ointment, ensure his/her hands are washed
  (unless the area being treated is the hands).

Nasal spray

• Ask the person to blow their nose or help clean the nasal passages with a tissue.
• Put the nozzle of the spray into the one nostril, keeping the bottle upright. Then close
  the other nostril by pressing a finger over the nostril.
• Ask the person to slowly breathe in through the nose. As the person does so,
  activate the spray (follow instructions on the product on how to do this).
• Take the nozzle out of the nostril and ask the person to breathe out through the
  mouth.
• Repeat for the other nostril if necessary.
• After using the spray wipe it clean each time with a clean tissue and replace the cap.

Skin patches

• Always apply patches to flat areas of skin where there is little movement.
• Do not apply patches to areas of skin where there are bends e.g. the elbows.
• Do not apply patches to areas of skin that have cuts, spots or other blemishes.
• Do not apply patches to very hairy areas of skin.
• Do not apply patches straight after a hot bath or shower.

• Wear disposable gloves.
• Before applying a new patch always remove any old ones. Do not apply patches to
  the same area of skin twice in a row – choose a different site.
• Make sure the skin where the new patch is going to be applied is completely dry,
  clean and cool before putting on the new patch.
• Carefully remove the patch from its packaging
• Remove a section of the sticky backing to the patch and apply the sticky part to the
  skin.
• Remove the remaining backing to the patch and press the whole patch onto the skin
  with the palm of your hand.
• To help the patch stick, press the whole patch to the skin with your palm for at least
  30 seconds. Make sure the patch sticks well, especially around the edges.

When you take off an old patch, fold it in half so that the sticky side sticks to itself. Put the
folded old patch into the packaging that the new patch has come out of and put this into
household waste immediately.

Inhalation devices (inhalers)

There are different types of inhaler device and how each one works is slightly different. It is
important that the instructions are followed carefully for these devices. Therefore, use of
different inhalers will be demonstrated during the workshop.

Some general points are:

• The person should always be in an upright position when using an inhaler.
• The person should breathe out before putting the inhaler in the mouth.
• The person’s lips should form a tight seal round the mouthpiece of the inhaler.
• The person should begin to breathe just before the inhaler is activated or to trigger
• the inhaler.
• The person should continue to breathe deeply and then hold their breath for about 10
  seconds.
• If more than one puff of the inhaler has been prescribed, there should be a gap of at
  least 30 seconds between puffs.

Some inhalers are also used with “spacer” devices. Inhalers fit into one end of a spacer
device and the person breathes through the other end. Common ones are AeroChamber®
and Volumatic®.

Mouthwashes

• Shake the bottle to mix the liquid, ensuring the top is on tightly.
• Using either a measuring cup or an oral syringe, measure out the correct dose. Many
  mouthwashes come with their own measure.
• Offer the measuring cup or oral syringe to the person.
• Ask the person to rinse the mouthwash around the mouth for the time stated on the
  product information.
• Ask the person to spit out the mouthwash. Remind the person not to swallow the
  mouthwash.
• Clean the neck of the bottle and any drips with a clean damp cloth before replacing
  the bottle top.

SPECIAL CIRCUMSTANCES

Refusal to take medicines

No one should be forced to take a medicine that they don’t want to. There are many reasons
why people refuse or don’t want to take medicines. Some are:

• The person does not need it – for example, the person is not currently in pain so
• does not need a painkiller.
• A belief that the medicine is not doing any good.
• Not knowing what the medicine is for.
• The medicine is, or the person thinks the medicine is, causing a side effect.

If a person has capacity and is able to make decisions about medicines (i.e. assisted level of
support), it is the person’s right not to take a medicine. Care staff should respect the
person’s right not to take a medicine, even if not taking it is bad for the person’s health.

If a person does not have capacity to make decisions about their own medicines (i.e.
managed level of support), every effort should be made to encourage the person to take
his/her medicines but the person should never be forced.

If a person is consistently refusing to take his/her medicines, you should discuss this with a
senior member of staff. It may be necessary to get advice from the person’s GP or
pharmacist: this should be done by a senior member of staff.

It is important to record if a person refuses to take medicines, including the reason for
this if it has been given.

Illness that causes dehydration

Some medicines should be temporarily stopped if a person has an illness that can result in
dehydration (vomiting, diarrhoea and fever). This is because these medicines can make
dehydration more likely or can lead to serious side effects if the medicine is taken by
someone who is dehydrated.
NHS Highland produces cards that list the medicines that should be temporarily stopped.
The person’s pharmacist or GP will provide a card to people who take these medicines:

Alcohol

If care staff are to assist or administer medicines to a person and discover the person to be
drunk, this should be reported to a senior staff member who will decide what action should
be taken. Some people will have planned actions stated in their care plans, others will
require advice from the person’s GP or pharmacist.

Side effects

A side effect is an unintended effect of a medicine. Most side effects are unwanted or
unpleasant, but some may be beneficial. Common side effects are nausea,
diarrhoea/constipation and drowsiness, but the range of potential side effects is huge. All the
side effects known for each medicine are listed in the patient information list provided with
the medicine.
If a person is experiencing a side effect, this should be reported to a senior member of staff
who will decide what action needs to be taken. Some side effects can be solved with simple
advice from a pharmacist, but others will require a medicine to be changed by the person’s
prescriber.

Dropped medicines

If a tablet or capsule is dropped during administration, it should be assessed to see if it can
still be administered. Any tablet or capsule that is sticky or wet, or dropped somewhere dirty,
should be safely disposed of. If it is dropped somewhere clean (eg, onto a clean table), it can
be administered immediately. Liquids and creams should not be scraped up and used. Skin
patches should only be used if they land sticky-side up.

Purchasing medicines

Care staff may be asked to purchase medicines for people who are receiving assisted
support with medicines. The person should be able to tell care staff exactly what medicines
to purchase: no decision should be made by care staff.

Care staff should not advise people on purchasing medicines or suitability of
medicines.

If care staff are asked to purchase medicines, the purchase should ideally be from the
community pharmacy that dispenses the person’s other medicines. This is so that a check
can be made to ensure that the purchased medicine is suitable and safe for that person e.g.
no interactions.
Where this is not possible or where the purchase is made from another retail outlet, other
than a community pharmacy, the person’s community pharmacy/dispensing GP practice can
advise if the medicine is suitable and safe.

Errors and incidents

People who are in residential care services, attending day care or who are receiving care in
their own homes can be at particular risk from medication errors. This is because this group
of people often have complex health problems and, as a result, can frequently be on a
number of different medicines.

An error, or mistake, happens when there is a failure to get the “FIVE Rs” or FIVE RIGHTS
correct. Remember that these are:

• RIGHT medicine
• RIGHT person
• RIGHT time
• RIGHT dose
• RIGHT route

Factors that can contribute to errors happening include:

• Lack of training for staff around medicines
• Interruptions when helping people with their medicines or administering medicines
• Poor communication between care staff, the GP practice and the community
• pharmacy
• Inaccurate medicine records.

If you think an error has happened with a person’s medicines it is VERY IMPORTANT that
this is reported. You should also report if there has been a near miss – this is similar to an
error but because action was taken to avoid it, any potential harm to the person was
avoided.

If, by accident, a medicine has not been taken or given then this is also an error.
If an error or near miss happens, you should report this IMMEDIATELY to a senior member
of staff. The senior member of staff will need to seek medical advice, normally from the
person’s GP, on what to do. The senior member of staff will also inform others too, such as
relatives/carers of the person.

There are two main reasons why errors and near misses need to be reported. It is not so
that someone can be blamed for what has happened but rather to:

• Make sure that the person’s health has not been affected and, if it has, to take action to minimise any damage to their health.
• Make sure that we can learn from what has happened to lessen the chance of it happening again, or a similar incident happening to someone else.

FURTHER TRAINING

Having completed this course, all care staff should receive training that is particular to their
area of work, whether that is working in a residential or day care service or helping care for
people in their own homes.

Training materials are available for different care settings that cover the following topics and
procedures:

• Roles and responsibilities of care staff and other professionals
• Who to ask for help and advice
• Ordering of medicines
• Collecting or receiving medicines
• Storage of medicines
• Record keeping
• Return of medicines for destruction
• The use of purchased medicines and (in residential care settings only) homely
• remedies

Legislation

All Medicines are controlled by the Medicines Act 1968.​

​This piece of legislation provides the legal framework for the production, distribution, importation, manufacture, licensing, prescription, supply and administration of medication​

The medicine act divides medication into three categories:​

• General Sales List (GSL) – these are medicines that can be purchased from any licensed retailer ​​
• Pharmacy only (P) – these are medicines that can only be sold or supplied under the supervision of a pharmacist​​
• Prescription only medication (POM) – these are medicines that can only be obtained with a valid prescription ​

​Other relevant legislation:

• Human Medicines Regulations (2012)​
• Misuse of Drugs Act 1971​
• Misuse of Drugs Regulations 2001​
• Misuse of Drugs (Safe Custody) Regulations 1973​
• Controlled Drugs (Supervision of Management & Use) Regulations 2013 (Amended 2020)​
• Data Protection Act 2018​
• GDPR 2018​
• Health and Safety at Work Act 1974 ​
• The Human Rights Act 1998​
• Reporting of injuries and Dangerous occurrences regulations 1995 (riddor)​
• Control of substances hazardous to health regulations 2002 (coshh)​
• Adults with Incapacity (Scotland) Act 2000​
• Mental Welfare Commission, Covert Medication, Legal and Practical Guidance (2006)​
• The Regulation of Care (Scotland) Act 2001​
• Community Care and Health (Scotland) Act 2002​
• Chronically Sick and Disabled Persons Act 1970​
• Disabled Persons (Service, Consultation and Representation) Act 1986 ​
• Mental Health (Care and Treatment) (Scotland) Act 2003​
•  Health and Social Services and Social Security Adjudication’s Act 1983​
• The NHS and Community Care Act 1990​
• SSSC Codes of Practice ​
• Health & Social Care Standards​

Legislation listed in bold are the most prominent pieces of legislation to consider.

CnES Medication Management Manual:

The British National Formulary

Below is a link to the BNF online, where you will be able to find out more about all the medications