Medication Incidents: Guidance for Commissioners

1. Introduction

This medication guidance for commissioners was developed in response to findings from a case audit, which highlighted concerns around medication practices.

The purpose of the guidance is to support commissioners of all regulated settings when updating and developing contract documentation in accordance with current legislation, statutory guidance and best practice.

2. Guidance relating to Safeguarding Adults

2.1. Current Legislation

Below is a list of the current legislation applicable to Safeguarding Adults that commissioners may consider referring to within contract documentation:

• The Care Act 2014
• Care Act 2015 Statutory Guidance – revised 2021
• The Mental Capacity Act 2005 (including Deprivation of Liberty Safeguards)
• The Mental Capacity (Amendment) Act 2021 (including Liberty Protection Safeguards), when implemented
• The Human Rights Act 1998
• The Equality Act 2010
• Mental Health Act 1983 and the New Code of Practice 2015
• Serious Crime Act 2015
• Modern Slavery Act
• Criminal Justice and Courts Act 2015
• Counter Terrorism and Security Act 2015
• Statutory Guidance on Female Genital Mutilation.

Current relevant legislation appropriate to medicines management includes:

• Misuse of Drugs Regulations 2001
• Human Medicines Regulations 2012
• The Controlled Waste (England and Wales) Regulations 2012
• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• Misuse of Drugs Act 1971

2.2 Six Principles

The Department of Health; Care and Support Statutory Guidance issued under the Care Act 2014, describes six principles that underpin all safeguarding adult work which applies to all sectors and settings including care and support services, further education colleges, commissioning, regulation and provision of health and care services, social work, healthcare, welfare benefits, housing, wider Local Authority functions and the criminal justice system. These principles should always inform the ways in which professionals and other staff work with adults.

• Empowerment – People being supported and encouraged to make their own decisions and informed consent. “I am asked what I want as the outcomes from the safeguarding process and these directly inform what happens.”
• Prevention – It is better to take action before harm occurs. “I receive clear and simple information about what abuse is, how to recognise the signs and what I can do to seek help.”
• Proportionality – The least intrusive response appropriate to the risk presented. “I am sure that the professionals will work in my interests, as I see them and they will only get involved as much as needed.”
• Protection – Support and representation for those in greatest need. “I get help and support to report abuse and neglect. I get help so that I am able to take part in the safeguarding process to the extent to which I want.”
• Partnership – Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse. “I know that staff treat any personal and sensitive information in confidence, only sharing what is helpful and necessary. I am confident that professionals will work together and with me to get the best result for me.”
• Accountability – Accountability and transparency in delivering safeguarding. “I understand the role of everyone involved in my life and so do they.”

Action: The above principles are referenced within contract documentation.

2.3 Types of Abuse

The Care Act recognises ten types of abuse as follows:

• Self-Neglect
• Domestic Abuse
• Modern Slavery
• Physical
• Sexual
• Financial
• Neglect and acts of omission
• Psychological
• Discriminatory
• Organisational

Action: There is reference to the 10 types of abuse within contract documentation.

Action: Commissioners ensure that Safe Recruitment practices are in place within commissioned services to ensure that staff employed within care services have been subject to the relevant checks.

2.4 Training

The Teeswide Safeguarding Adults Board has developed a training strategy that outlines a learning and development framework to support all those working with adults who are experiencing, or at risk of, abuse and neglect. This framework is aligned with the Teeswide Inter-Agency Safeguarding Adults Policy and Procedure, and aims to ensure that individuals are equipped to respond appropriately.

Full details of available training and e-learning opportunities can be found on the TSAB Training page, which reflects the principles set out in the strategy¹

The Training Strategy states that all organisations involved in direct work with adults who may be at risk of abuse must ensure that all new and existing employees have completed the Foundation Level training and that this training is refreshed every three years. The TSAB annual training plan outlines specific safeguarding competencies and these have been aligned with the Bournemouth Safeguarding Adults Competency Framework, the Intercollegiate document; Adult Safeguarding: roles and competencies for health care staff² and the National Institute for Health and Care Excellence (NICE) guideline for Safeguarding Adults in Care Homes³.

Action: That contract documentation is amended to reflect the minimum requirement to refresh Adult Safeguarding training every 3 years and contract compliance visits include monitoring to ensure this is implemented within commissioned services.

2.5 Resources

The TSAB website provides a whole range of resources to assist providers in delivering a safe service. These resources include:

• A standard template for developing a Safeguarding Adults Policy
• A range of guidance documents
• A regular newsletter highlighting current issues, best practice and TSAB priorities
• A ‘Find Support in Your Area’ section to enable providers and professionals to easily access details of services providing a range of support across Tees
• Access to free Safeguarding Adults E-Learning

Action: Commissioners regularly promote the TSAB website and training resources with care providers, for example; by circulating the TSAB newsletter.

2.6 The TSAB Inter-Agency Safeguarding Adults Policy and Procedures

The TSAB works in partnership to safeguard and promote the wellbeing and independence of adults living in the Boroughs of Hartlepool, Middlesbrough, Redcar & Cleveland and Stockton-on-Tees, who are experiencing, or at risk of abuse or neglect. The most current version of the agreed policy and procedures are published on the TSAB website: www.tsab.org.uk.

Action: Commissioners must ensure that new and existing contract documentation includes reference to the implementation of the agreed Teeswide Policy and Procedures. Any references to previous policies and procedures must be removed as they are not compliant with the Care Act 2014.

2.7 Responding to and Addressing Serious Concerns with Providers

The TSAB has the above policy and procedure in place which sets out the framework for dealing with serious concerns in health and care settings on a multi-agency basis whilst maintaining the focus on the adult(s) experiencing or, at risk of abuse or neglect.

Action: Commissioners must make reference to this policy and procedure within their contract documentation making providers aware of the potential action that can be taken when there are concerns about a service.

3. Guidance relating to Medication Errors

3.1 TSAB Medication Error Guidance for Providers

TSAB have published guidance for health and care providers outlining the requirements for reporting medication errors as a safeguarding concern. This guidance provides clear information for determining when a medication issue becomes a safeguarding concern.

Action: Where the contract is relevant to medication, commissioners and contract monitoring officers actively signpost commissioned services to the TSAB Practice Guidance for Reporting Medication Incidents into Safeguarding to assist with the development of a consistent approach for reporting medication errors as a safeguarding concern.

Action: As part of the contract compliance process, procedures are put in place to ensure that providers follow the published TSAB Practice Guidance for Reporting Medication Incidents into Safeguarding and any regulatory reporting requirements.

3.2 NICE Standards, Guidelines and Pathways

NICE has published specific guidelines for Care Homes⁴ and Home Care⁵ in relation to medicines management: by using and implementing these resources providers will be following best practice and therefore be less likely to experience medication errors. More specifically a process for safeguarding and handling medication errors is included within the pathway section of Medicines Management⁶. This pathway suggests the following relevant actions for commissioners:

• Commissioners and providers of health or social care services should ensure that a robust process is in place for identifying, reporting, reviewing and learning from medicines errors involving residents.
• Commissioners and providers of health or social care services should be aware of local arrangements for notifying suspected or confirmed medicines-related safeguarding incidents.
• Commissioners should ensure that reporting requirements are included in commissioning and contracting arrangements.

The relevant NICE standards, guidelines and pathways should be adhered to by all commissioned providers in relation to medicines management. Previously, particularly in home care services, there has been reference to the North East of England Domiciliary Care; Safe Handling, Management and Administration of Medication – Model of Good Practice. It should be noted that the NICE Standards, Guidelines and Pathways supersedes this document and it is no longer current.

Action: Contract documentation is updated to include reference to the relevant NICE guidelines.

Action: As part of the contract compliance process; medication policies and procedures are monitored against the standards set out by NICE and/or relevant local guidance (ICB).

3.3 Other Good Practice Guidance

The North of England Commissioning Support Unit (NECS) Vulnerable Adults Workstream Group has produced a suite of guidance documents and tools for use across all North East and Cumbria ICB, based on national standards, legislation and guidance. PrescQIPP also provide care home focused resources and can be accessed on their website⁷.

Action: Commissioners should signpost care services to this useful resource⁸, where relevant.

3.4 Medication Practice Issues

The Medication Audit found that some providers were not compliant with the relevant NICE guideline for their service, some of the most common issues raised were:

• Care providers were not always proactive in ensuring that regular medication reviews were undertaken by health professionals
• There was in some instances a lack of robust procedures in relation to the covert administration of medication
• Medication Audits were not routinely undertaken in line with the provider’s policy and procedures
• Monitoring, analysis and learning from medication incidents was not routinely carried out by all providers

During the peak of the COVID-19 pandemic, there was a noticeable decline in the number of medication-related Safeguarding Concerns being raised, as well as a reduction in Section 42 Enquiries, particularly within nursing home settings. In the post-COVID period, however, the number of medication Safeguarding Concerns has doubled. This increase has not been mirrored by a corresponding rise in Section 42 Enquiries. Reports from care homes, especially residential care homes, continue to highlight issues related to medication. Ongoing, targeted monitoring of these recurring concerns in specific settings is essential to ensure that Local Authorities and the Teeswide Safeguarding Adults Board (TSAB) can be confident that medication practices are being robustly overseen. It is suggested that the following measures are best practice:

• Closer monitoring of care plans to ensure that medication reviews are carried out at least annually
• Commissioners to ensure that providers follow the required procedures to implement covert administration of medication, if the person is deemed to lack mental capacity in respect of their medication
• Commissioners specify within their contract documentation the requirement to carry out medication audits within specified timescales and monitor the quality and frequency of audits
• Commissioners agree processes with their respective Safeguarding Adults’ Leads to monitor Medication Incident Logs and internal investigation outcomes as outlined in the Practice Guidance for Reporting Medication Incidents into Safeguarding.

Action: Contract documentation, compliance tools and processes to be updated to include reference to the medication practice issues as outlined above. To assist with this, commissioners can use the following web link: Care Homes – Implementing NICE guidelines and encouraging best practice

3.5 Medication Training Requirements

Providers should indicate within their Medication Policy and Procedures the training they expect their staff to achieve to enable them to carry out medication duties. As a minimum this must include the completion of HSC 3047: Support use of medication in care settings. All training should align with the expectations of the regulator (CQC) and their commissioners (Local Authorities and/or Clinical Commissioning Groups). See Appendix 1 for NICE guidelines.

Action: Commissioners must ensure robust systems are in place for monitoring compliance against staff training requirements.

4. Appendix 1 – NICE guidelines for Care Home staff administering Medication

Care home staff must have the training and skills to use system(s) adopted in the care home for administering medicines in line with regulation 22 of the Health and Social Care Act 2008 for adult care homes and regulation 26 of the Children’s Homes Regulations 2001 for children’s care homes.

Care home providers must ensure that designated staff administer medicines only when they have had the necessary training and are assessed as competent. Care home providers must ensure that staff who do not have the skills to administer medicines, despite completing the required training, are not allowed to administer medicines to residents.

Care home providers should set up an internal and/or external learning and development programme so that care home staff can gain the necessary skills for managing and administering medicines. The programme should meet the requirements of the regulators, the residents and the training needs of care home staff.

Care home providers should consider using an ‘accredited learning’ provider so that care home staff who are responsible for managing and administering medicines can be assessed by an external assessor.

Care home staff must have induction training that is relevant to the type of home they are working in (adult care homes or children’s homes). All care home staff (including registered nurses as part of their continuing professional development) involved in managing and administering medicines should successfully complete any training needed to fulfil the learning and development requirements for their role.

Care home providers should ensure that all care home staff have an annual review of their knowledge, skills and competencies relating to managing and administering medicines. Care home providers should identify any other training needed by care home staff responsible for managing and administering medicines. If there is a medicines-related safety incident, this review may need to be more frequent to identify support, learning and development needs. Health professionals working in, or providing services to, care homes should work to standards set by their professional body and ensure that they have the appropriate skills, knowledge and expertise in the safe use of medicines for residents living in care homes.