Policies & Procedures
Medications Policy & Procedure v2.0
Medications Policy and Procedure
Policy Lead Mrs. Tavleen Sharma (Registered Manager)
Version No. 2.0
Date of issue April 2026
Date to be reviewed April 2027
Purpose and Introduction
The purpose of this policy is to ensure that VCare Consultancy Services Limited (“VCare”) manages medicines safely, effectively, consistently and in accordance with:
- Care Quality Commission (CQC) Regulations;
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014;
- NICE Guideline SC1 – Managing Medicines in Care Homes;
- Royal Pharmaceutical Society guidance;
- Mental Capacity Act 2005;
- Misuse of Drugs Act 1971;
- South Gloucestershire Council contractual expectations;
- Current best practice guidance relating to medication management in health and social care settings.
This policy aims to:
- protect service users from harm associated with medicines;
- support safe administration and handling of medicines;
- promote person-centred medication support;
- ensure staff competence and accountability;
- reduce medication errors and safeguarding risks;
- ensure accurate documentation and reporting.
Scope
This policy applies to:
- all VCare employees;
- registered managers;
- care coordinators;
- healthcare support workers;
- agency workers engaged by VCare;
- any person supporting service users with medicines under VCare services.
The policy applies to:
- domiciliary care;
- supported living;
- community support;
- live-in care;
- respite care;
- partnership and wellbeing support services.
Principles
VCare is committed to:
- promoting independence wherever possible;
- respecting dignity, privacy and choice;
- ensuring medicines are managed safely and lawfully;
- involving service users and families in decisions;
- maintaining accurate records;
- ensuring only trained and competent staff support medication;
- reducing avoidable medication errors;
- ensuring concerns are escalated promptly.
Medication support will always be delivered in accordance with:
- the individual’s assessed needs;
- the care and support plan;
- risk assessments;
- consent and capacity arrangements.
Definitions
Medication Support: Any assistance provided to a service user relating to medicines.
Administration: Direct involvement in giving medication to a service user.
Prompting: Reminding or encouraging a person to take their own medication.
MAR Chart: Medication Administration Record
Controlled Drugs: Medicines subject to additional legal controls under the Misuse of Drugs legislation.
Responsibilities
Registered Manager: Responsible for:
- ensuring implementation of this policy;
- ensuring staff training and competency;
- monitoring medication practice;
- investigating medication incidents;
- ensuring safe systems and audits;
- liaising with healthcare professionals;
- ensuring safeguarding concerns are escalated.
Care Staff: Responsible for:
- following care plans and MAR charts;
- only undertaking medication tasks they are trained and authorised to perform;
- documenting medication support accurately;
- reporting concerns immediately;
- maintaining confidentiality;
- following infection prevention and control procedures.
Service Users: Will be encouraged to:
- remain independent where safe;
- communicate medication concerns;
- participate in medication reviews;
- provide consent where appropriate.
Consent and Mental Capacity
VCare will:
- presume capacity unless assessed otherwise;
- seek valid consent before medication support;
- follow Mental Capacity Act 2005 principles;
- ensure best-interest decisions are documented;
- involve families and professionals appropriately.
Medication must never be administered covertly unless:
- authorised through a formal best-interest process;
- approved by relevant healthcare professionals;
- documented within the care plan.
Assessment and Care Planning
Prior to providing medication support, VCare will complete:
- medication risk assessment;
- medication needs assessment;
- consent assessment;
- capacity assessment where appropriate;
- allergy and adverse reaction review;
- support planning.
Care plans will include:
- medication name;
- dosage;
- route;
- timing;
- support required;
- known allergies;
- PRN protocols;
- escalation arrangements.
Care plans and medication records will be reviewed regularly and updated when changes occur.
Levels of Medication Support
VCare may provide:
Level 1 – Prompting
Staff remind or encourage service users to take medicines independently.
Level 2 – Assistance
Staff may assist with opening packaging or preparing medicines where the service user retains control.
Level 3 – Administration
Staff administer medication directly in accordance with assessed needs and training.
Only trained and competent staff may administer medicines.
Medication Administration
Medication administration must follow the:
“6 Rights”
- Right person
- Right medication
- Right dose
- Right time
- Right route
- Right documentation
Staff must:
- check medication labels carefully;
- confirm identity of the service user;
- check expiry dates;
- wash/sanitise hands;
- follow infection prevention procedures;
- record administration immediately after support;
- never sign MAR charts in advance.
Medication must only be administered in accordance with:
- pharmacy label;
- MAR chart;
- GP/pharmacist instructions;
- approved protocols.
PRN Medicines
PRN (“when required”) medicines must:
- have clear written guidance;
- specify indication for use;
- specify maximum dose;
- specify minimum intervals;
- include escalation guidance.
Staff must document:
- reason for administration;
- effectiveness observed;
- any concerns identified.
Controlled Drugs
Controlled drugs will be managed in accordance with legislation and best practice.
VCare staff will:
- follow controlled drug recording requirements;
- maintain appropriate documentation;
- report discrepancies immediately;
- escalate concerns promptly.
Where VCare staff are responsible for administration within regulated environments, double-checking arrangements will be followed where required.
Storage of Medicines
Medicines must be:
- stored safely and securely;
- stored in original packaging;
- stored according to manufacturer instructions;
- inaccessible to unauthorised persons;
- temperature controlled where required.
Staff must report:
- damaged medication;
- expired medicines;
- missing medicines;
- storage concerns.
Refusal of Medication
Service users have the right to refuse medication unless subject to lawful restrictions.
Where medication is refused, staff must:
- remain calm and respectful;
- encourage but not force compliance;
- record refusal clearly;
- report repeated refusals;
- escalate concerns to family/professionals where appropriate.
Medication Errors and Incidents
Medication incidents include:
- missed medication;
- wrong medication;
- wrong dose;
- incorrect timing;
- omitted signatures;
- refusal not recorded;
- administration without authority.
Where an incident occurs, staff must:
- Ensure the service user is safe.
- Seek medical advice where required.
- Inform the Registered Manager immediately.
- Complete incident documentation.
- Inform relevant healthcare professionals/family where appropriate.
- Participate in investigation and learning.
Safeguarding referrals will be made where appropriate.
Training and Competency
VCare will ensure that staff receive:
- medication awareness training;
- medication administration training;
- competency assessments;
- refresher training;
- supervision and spot checks.
Competency assessments will include:
- observation of practice;
- MAR chart completion;
- understanding of escalation procedures;
- infection prevention and control.
Staff will not administer medication until assessed as competent.
Auditing and Quality Assurance
VCare will undertake:
- MAR audits;
- medication spot checks;
- incident trend analysis;
- supervision reviews;
- competency reassessments;
- governance reviews.
Learning from incidents and audits will be used to improve practice.
Record Keeping
VCare will maintain accurate records relating to:
- medication administration;
- refusals;
- incidents;
- PRN administration;
- audits;
- competency checks;
- medication changes.
Records will be:
- accurate;
- contemporaneous;
- secure;
- confidential;
- retained in accordance with GDPR and retention requirements.
Safeguarding
Medication misuse, unsafe administration or unexplained discrepancies may constitute a safeguarding concern.
VCare staff must:
- report concerns immediately;
- follow safeguarding procedures;
- cooperate with investigations;
- prioritise service user safety.
Equality, Diversity and Inclusion
Medication support will be delivered in a manner that respects:
- cultural needs;
- religious beliefs;
- communication needs;
- disability-related adjustments;
- protected characteristics.
VCare will make reasonable adjustments wherever possible.
Business Continuity
VCare will maintain contingency arrangements to ensure continuity of medication support during:
- staffing shortages;
- emergencies;
- severe weather;
- IT failure;
- service disruption.
Related Policies
This policy should be read alongside:
- Safeguarding Policy
- Infection Prevention and Control Policy
- Health and Safety Policy
- Equality and Diversity Policy
- GDPR and Confidentiality Policy
- Incident Reporting Policy
- Business Continuity Policy
- Complaints Policy
Monitoring and Review
This policy will be:
- reviewed annually;
- reviewed following incidents or regulatory changes;
- monitored through audits and governance arrangements.