Information required before staff may assist with medication

8.1 We will not provide support with medication until we have carried out a risk assessment of medication related risks (including how medication will be stored) and determined that support is necessary.  We will record the outcome of the risk assessment in the person’s plan.

8.2 Wherever possible and safe, we will support people to become more independent with their medication. This may involve a trial period monitored by staff during which the person manages their own medication. We will review the trial immediately if the person or other people using the service are at risk of harm. 

8.3 We will keep risk assessments under review and re-assess risks as appropriate, for example before off-site activities; at any time when there is any doubt about the person’s ability to take their medication as prescribed and / or store it safely; when the person is being discharged or is transferring to another service. 

8.4 Risk assessments must consider: 

• the person’s ability to manage medication safely
• risks of misuse, overdose or self harm
• storage risks in shared or communal environments
• risks to other people using the service, particularly children and young people

8.5 Consent must be obtained before any support with medication is provided.

8.6 Adults and young people aged 16–17 are presumed to have capacity to consent unless there is reason to doubt this, in which case a mental capacity assessment will be completed in line with the Mental Capacity Act 2005.

8.7 Children under 16 may consent to medication support where they are assessed as Gillick competent. Where a child is not competent, consent must be provided by a person with parental responsibility or through the court.

8.8 For looked‑after children and young people, consent and decision‑making must align with the placement plan and delegated authority arrangements.  

8.9 We will assume that anyone who is 16 or over has mental capacity to provide consent.  If there are doubts about a person’s capacity to consent to medication, a mental capacity assessment will be undertaken. 

8.10 Where we have determined that the person lacks mental capacity, consent may be provided by anyone authorised under the Mental Capacity Act to make personal welfare decisions on their behalf.   If there is no such person, we will follow the Gloucestershire Multi Agency Mental Capacity Act policy and guidance to reach a best interest decision.

8.11 For children and young people:

• Children under 16 may consent if assessed as Gillick competent
• Where a child is not competent, consent must be obtained from a person with parental responsibility or the court
• For looked-after children, decisions must align with the placement plan and delegated authority arrangements
• Young people aged 16–17 are presumed to have capacity but remain subject to safeguarding and care planning frameworks

8.12 We will record in the person’s plan:

• whether or not the person requires support to safely manage their medication
• the exact nature of any support required from staff and where relevant any staff monitoring responsibilities, for example when someone is managing their own medication including during a trial or reablement period. 

8.13 We will review and update the plan at regular intervals and whenever there is any change to:

• the person’s health, care or medication support needs
• the support or monitoring required from staff

8.14 All medication may cause harm if it is not administered according to the prescriber’s or manufacturer’s instructions.  We will not provide support with medication until we have all the information set out in this section. 

8.15 Staff must immediately update the information whenever there is any change to:

• the person’s medication, for example when a medication is started, stopped or a dose is changed
• the support required from staff.

8.16 All medications – the person’s record must include these details:

• the full name and date of birth of the person to whom medication is to be administered 
• A picture with a clear view of the person’s face
• any known drug sensitivities e.g. to penicillin, aspirin 
• the name of the medication to be administered
• the reason (clinical condition) why the person is taking the medication
• the form of the medication e.g. tablets or liquid 
• the amount in the bottle/container supplied to the home / day centre
• the strength of the preparation 
• the required dose 
• the route of administration e.g. by mouth 
• the time(s) or frequency that the medicine is to be administered 
• any special instructions e.g. whether it should be given before or after food.  

8.17 As and when required medications – the person’s record must include these additional details: 

• the circumstances in which the medication is to be given
• how much medication is to be given
• what the medication is expected to do, for example help them breathe more easily
• whether a dose can be repeated and if so:
  • the minimum time between doses if the initial dose has no effect, and
  • the maximum dose which can be taken within 24 hours. 

8.18 Variable dose medications - Prescribers may alter the dose of a variable dose medication following a blood test. 

8.19 If the person has had a blood test and no advice has been received from the prescriber; staff must check with the prescriber to see if the dose has changed. If it has, staff must ask the prescriber to confirm the correct dose in writing and update the person’s record.

8.20 Over the counter products – These may be provided for general use in some services or may be brought into the service by family, carers or those with parental responsibility.  

8.21 Staff must check with the person’s GP or a pharmacist about whether an over-the-counter product might interact with a prescribed medication. Staff must record the advice in the person’s record and where relevant discuss the advice with the person and / or their family.