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Serenity Health has a duty of care to store and administer client’s medication in a safe and responsible way.  We follow strict guidelines and protocol as outlined by CQC. 




Care Quality Commission (CQC) Outcome 9: Management of medicines, states that people using a service regulated by CQC:


  • Will have their medicines at the times they need them and in a safe way
  • Wherever possible will have information about the medicine being prescribed, made available to them or others acting on their behalf.


This is because providers who comply with the regulations will:


  • Handle medicines safely, securely and appropriately
  • Ensure that medicines are prescribed and given by people safely
  • Follow published guidance about how to use medicines safely.







The Registered Manager at Serenity Health


It is The Registered Manager’s responsibility to:


  • Ensure that safe systems of ordering, receipt, storage, administration and disposal of medicines are in operation within the Serenity Health premises.
  • Ensure safe custody of all medicines (including controlled drugs) within the Serenity Health premises.
  • Ensure that the assistant manager on duty is trained to take responsibility for management of medicines within Serenity Health premises, in their absence.
  • Recognize that medicines are the property of the client, and they should be given the choice of controlling their own medication.
  • Ensure that all staff at Serenity Health that are involved in medication administration have received appropriate training for their level of administration and competency.
  • Ensure medication records are maintained and kept for the required period of time.
  • Ensure that there is a system in place to ensure adequate supplies of medication are always available.



Staff at Serenity Health


It is the responsibility of staff at Serenity Health to:


  • Follow the care plan and this policy.
  • Provide the level of support specified in the care plan:


  1. Level 1 support (which includes reminding/prompting residents who self-administer their medications) in accordance with the care plan and the resident’s instructions.


  1. Provide Level 2 support (which includes administration of medications) in accordance with the care plan and the prescriber’s instructions.


  • Follow the procedure for administration of medicines and the use of MAR charts.
  • Record Level 1 support in the care record
  • Record Level 2 medication administration/assistance on the MAR chart provided.
  • Be alert to factors which might pose a risk to the resident, and report concerns to the Registered Manager. If the Registered Manager is not available, concerns may be reported to the deputy manager on duty.


  • Immediately report any mistakes in the administration of medication including omitted doses, to the Registered Manager or assistant manager on duty which will then inform CQC.
  • To promote self-administration where appropriate.
  • Document refusal of medication by resident.


Serenity Health workers are only accountable for medication they themselves administer or assist with.




  • The training provided for Serenity Health Managers, Assistant Managers, Counsellors and support workers must incorporate the requirements of this policy.


  • The Registered Care Home Manager must ensure that a record of training for medication administration is available for every Serenity Health employee. This must include the date the training was completed and the name and signature of the trainer. Annual competency assessments in medicines administration are to be completed for all Serenity Health employees. This annual competency assessment must be documented and signed off by both the employee and the Registered Manager. This training record must be made available for inspection by the Care Quality Commission (CQC) Inspectors upon request.







The following standards apply to this procedure:-

  • Clear and accurate records of all work are kept and apart from exceptional circumstances people have access to what is written about them.


  • Personal information is treated as confidential and apart from exceptional circumstances is not shared with other people without the agreement of the person to whom it relates.



  1. When a service user commences a service or commences the use of medication, a Medication Entry/Return Form must be completed. This should include Prescription Required as Needed (PRN) medication. This should detail:


  • Name of service user.
  • Name and strength of medication.
  • Dosage (amount) to be given and time of day (complying with frequency requested).
  • Date of entry and quantity of medication to unit.
  • Signature (of staff member entering details of medication).
  • Date and quantity of medication returned (to carer), where appropriate.
  • Signature and name (of staff recording the return of medication to carer).
  • Route of medication (e.g. orally).
  • Special Instruction – e.g. storage, if medication should be taken before or after food, purpose of PRN medication etc.

Any allergies to medication.


  1. All medication arriving with the service user must be recorded on the MAR sheet completed for the individual service user. This serves two purposes. The first being a record of medication in the unit and the second, a ‘check list’ for medication to be returned to pharmacy or on discharge with client.


  1. When ‘checking in’ medication, details must be written on the Medication Record Form for each client. The instructions on the labels should match the instructions on the Mar sheet. If this is not the case, staff need to ascertain from GP the correct dose before administering the medication.


  1. Medication Administration Records Sheets (MARS) sheets are in the Admissions, Detox and Doctors folder on the server.


  1. It is important to stress that the staff members checking the medication in will be taking responsibility for it and for the correct recording of details of administration. As well as checking the dosage on the bottles or pack it is essential that staff ascertain if any instructions have been sent in by relatives/carers. Any of these details must be recorded on the Mar sheet.






  1. All medication should be examined for information about storage conditions and these conditions must be adhered to. All medication, this includes Homely Remedies, must be stored in a lockable facility in a lockable room, with the key accessible to delegated staff only. The keys should be in the personal possession of identified staff. It is not appropriate to keep the key in a known location such as a drawer, hook or unlocked key press. Serenity Health service has designated a secure area (TOP kitchen) for medication storage and administration. This will house a lockable cabinet, ideally one that cannot be easily removed, a sink, if possible, and a lockable refrigerator. It is also necessary to provide separate storage for internal and external use only medicines. If controlled drugs are kept on the premises then a Controlled Drugs cupboard must be provided. This cupboard must have a certificate for its use from the provider, must be of a certain thickness and fixed to a permanent wall. A GP and/or prescribing pharmacist will be able to advise if a drug is a ‘controlled drug’. If a drug is/or may be required urgently, e.g. steroid, then it can be kept in a place for easy access but this must be based on risk and individual circumstances.


  1. The current medication charts or Medication Administration Record sheets (MARS) must also be kept in the room for easy access and use. When complete they should be transferred to the case file.


  1. The lockable storage used for medications MUST NOT be used for anything else. It should be labeled ‘Medicine Storage ONLY’. Storage facilities also need cleaning on a monthly basis using a suitable detergent. It is the responsibility of the manager to ensure this is implemented.


  1. Some medications, e.g. antibiotic suspensions, require storage in a refrigerator, which should be for medication ONLY and locked – this applies particularly to registered homes and where possible in other settings. If medication needs to be kept in the refrigerator then an appropriate refrigerator is to be purchased and permission from the Operations Manager sought immediately. This will be agreed on grounds of health and safety and the wellbeing of client.


  1. The refrigerator should be labeled ‘Medicine Storage ONLY’. It also needs cleaning on a monthly basis using a suitable detergent. Temperature needs to be set according to the storage conditions required for the medications and checked and recorded on a weekly basis. It is the responsibility of the manager to ensure that these actions are implemented. If adjustment of the thermostat fails to maintain the correct range of storage conditions/ temperatures then:


  • Consult with your pharmacist as to what should be done with the medications.
  • Initiate remedial works on the refrigerator.
  • Inform the client.


  1. No medication prescribed for an individual client can be kept at the unit unless the client is resident at the time, or attending the day service. All medication must be returned to pharmacy or destroyed when no longer required. (See: Disposal of Medication). Medication checks for all unused medication must be returned to pharmacists; this should be done every two weeks.


  1. In relation to storage, a separate area of shelf in the cupboard, or a box to keep each client’s medicines is a recommendation. However, given the nature of supply of medicines through NHS prescriptions, each client must have individual bottles/ containers of medicines.


  1. All staff need to know when a client is on medication and therefore communication with other services is two way and vital.


  1. There is a need to notify and take action when medication is running out.





Homely Remedies



  1. Homely Remedies brought in by the service user must be entered on MARS Sheet.


  1. Homely Remedies stock medication (where provided by the service) must be limited to paracetamol tablets and suspension e.g. cough medicine. A record of stock medication must be entered on MARS sheet, separately detailing all medications kept as stock e.g. paracetamol tablets, suspension 250mg/5ml, suspension 120mg/5ml and cough expectorants. Details regarding the name and the strength of the medication, e.g. paracetamol tablets 500mg or paracetamol suspension 250mg/5ml, must be recorded under medication name.


  1. If a client brings their own homely remedies in then care staff must understand to treat it as prescribed in relation to following the procedures.



  1. In terms of homely remedies interacting with prescribed medicines then there is a duty of staff to investigate, and if necessary contact a Pharmacist or the client’s GP for advice. It is important for staff to know what they are doing and what they are administering. We have a duty of care to understand what the medication is and its purpose.


  1. It is suggested that a list of homely remedies is kept in each unit and if appropriate, the list is sent to GPs with a standard letter for agreement for each client.


  1. The suggested remedies are:-


  • Paracetamol
  • Simple Linctus
  • Magnesium Tri-sil mix
  • Lactalose


  1. When homely remedies are administered then precise dosage must be given and advice sought from a GP or Pharmacist within twenty-four hours if continued dosage is given, unless a GP has given agreement to administer it.


  1. In order to assist staff in administering homely remedies reference sources must be available for each unit. These must be either contacting the supplying Pharmacist, the twenty-four hour NHS Help line and/or a copy of the BMA guide to medicines, kept in the unit.


  1. If homeopathic remedies are used by the client, e.g. Tea Tree Oil, Oil of Evening Primrose, then seek advice from the GP/Pharmacist about its use and particularly in relation to combination with prescribed medicines.






Prescription Required as Needed (PRN) Stock Medication



  1. Arrangements can be made for some client’s to hold PRN medication in their own property (unless it needs to be refrigerated), which can be administered, as needed e.g. asthma inhalers. A risk assessment will be needed. (See Self Medication).

Records of “Homely Remedies” and PRN Stock


  • Records must ensure that the following details are recorded:
  • Date.
  • Amount of medication in stock, e.g. 12 tablets.
  • Amount used for that administration, e.g. 1 tablet.
  • Name of service user administered to.
  • Balance left e.g. 11 tablets.
  • Staff signature.



  1. Where there is the possibility of confusing two clients because of similarities of names etc., an additional means of identification should also be used i.e. photograph.


  1. In the case of suspensions the balance cannot be entirely accurate. However, if an unopened bottle contains 200ml, then an estimate can be made after each dose given, e.g. 5ml given = 195ml remains in stock.


  1. All medication needs to be clearly labelled, checked that it is correct and expiry date noted from the label. The Care managers must ensure that there is a weekly stock take to ensure that all medication is in order, expiry dates are noted and action taken, particularly if medication is running low. (See Disposal of Medication)







  1. No out of date medicines, discontinued medicines or medicines that are the property of a client who is a non-resident (or in respite) or not attending aftercare, are to be kept. Out of date medicines for disposal must be kept separate from medicines in use.


  1. Medicines must be disposed of within a maximum of two weeks. If a client dies medicines need to be kept at the unit for 7 days, in case the coroner requires them.


  1. To comply with The Environment Protection Act 1990, all unwanted medicines must be returned to the supplier or local pharmacist for safe disposal. A record of all returned medicines must be kept at the unit. This record must include not only medication name, but also the quantity for disposal. This must be kept at the unit and also a copy to the Pharmacist.







  1. The times of administering medication are essential and there are often set times.


  1. It would be desirable if the client were brought to the medical/designated room rather than medication taken to the client. However, it must be recognized that this is not always acceptable and appropriate and can be classed as institutionalization. Notable exceptions include:


  • Where a client require their medication with food.


  • Other situations e.g. clients in wheelchairs or ill in bed.


  1. It is now advised that only 1 worker should check ALL drug administrations. However, this must not be an agency staff member.


  1. The important thing is to prevent distraction.


  1. There is a need for managers and all staff to recognize the pressure on staff and this can affect the administration of medication. There is a need to be clear about the names of medication as the brand name and the generic name can be different. If there is any confusion staff must check before administering. If in doubt do not administer but take advice immediately. ALL STAFF


  1. Staff must check medication record( MAR sheet ) and label of medication to be administered for: –


  • Correct service user name.
  • Correct time and date.
  • Medication name.
  • Correct strength.
  • Correct dosage.
  • Expiry date.
  • Any special instructions e.g. dosage spoon or if administration implement is required.
  • Check service user’s identity.



  1. Medicines must be prepared from the original labeled container at the point of administration and not pre-prepared except in special circumstances. Tablets and medications must not be handled, although it is recognized that often clients will handle tablets.


  1. Staff must check that medication has been taken and swallowed. If not taken, a record must be made on the client’s file. If a client refuses their medication then there may well be circumstances that require immediate confirmation (e.g. GP advice) but this is by no means the accepted normality. Staff must identify those clients where this will apply and provide specific guidance about reasonable actions in these cases. Clients may elect to refuse medication and this will not normally be referred to the GP at every refusal.


  1. Staff to sign or initial to say the correct client had the correct medication and amount at the correct time.




Refusal to Take Medication


  1. If a client refuses his/her medication, verbal encouragement should be used, offer the medication again to the client as soon as possible. If he/she still refuses then record listed code MARS sheet and record the incident in the clients notes. If necessary inform carers/relatives as soon as possible.


  1. No double doses should ever be given e.g. if a service user refuses one dose do not give two doses the next time round. The MARS sheet can be used to include PRN medications using appropriate code if it is offered and refused and record comments.



  1. If medication is dropped on the floor or wasted this must be recorded and advice taken e.g. from GP or pharmacist on the effect of not taking medication.






Mistakes in Administration of Medication


  1. If mistakes are made then advice must be sought immediately from GP or pharmacist, particularly if medication is missed or a double dose is accidentally given. There is a 24-hour NHS Direct helpline 0845 46 47.


  1. All staff involved in the medication error should submit a written statement immediately as to their understanding of the incident. These statements must be from: –


  • The person making the error.
  • The person reporting the error.
  • The unit manager on duty.
  • The report of the incident must immediately be presented to the appropriate line manager for action.


  1. The Care home manager must contact the CQC immediately.


  1. Each unit will hold a record of staff names, signatures and initials – in order to identify who administered medication from the MAR sheet. This list is to be made available if requested by the National care Standards Commission and CQC.


  1. There are two types of medication:


  1. a) Prescribed Regular Medication.
  2. b) Medication to be given as required (Homely Remedies or Prescription Required as Needed (PRN)).








Prescribed Regular Medication



  1. When writing up use MAR Sheet for prescribed regular medication.


  1. Always complete client’s name and DOB and put the current month and year on the form.


  1. Ensure full name of medication is written and the strength, e.g. 200mg/5ml or 200mg tablets.


  1. Write dose to be given and when to be given.


  1. If creams are to be administered please remember to write clearly where they are to be put, e.g. on elbows, face, buttocks or foot (which foot/elbow etc.). Always allow client to administer this themselves, if this is in a difficult position use PPE. Medication to be given as required and Prescription Required as Needed (PRN)


  1. There are two types of medication under the ‘as and when required’. The first is standard and is medication such as for headaches, coughs etc.


  1. When writing up MARS sheet ‘Homely Remedies or ‘PRN’ medication brought in by the client:


  • Always complete client’s name and DOB, and put the current month and year on the form.
  • Ensure full name of medication is written and the strength, if appropriate.
  • Write actual dose to be given – do not give a range of doses, e.g. 5–10 ml. (This causes confusion as to what to give or what has been given).
  • Indicate the frequency that the medication can be given, e.g. four hourly, and if there is a limit to the number of doses that can be given, e.g. no more than four doses in 24 hours. Ideally, it must be exact times stated.
  • Check whether there are any contra-indications.


  1. ‘Over the counter’ medication will have no pharmacy label on it. If a client wishes such medication to be administered, it must be checked on the bottle/box that a suitable dose can be given for that service user. If in any doubt, then staff must check with the Serenity Health GP or a duty doctor. Over the counter medication must only be given in exceptional circumstances rather than on a regular basis. These medications must also be recorded in the same manner.


  1. When writing up and giving paracetamol or Calpol, remember:


  • Paracetamol tablets are 500mg.
  • Calpol or paracetamol suspension comes in 2 strengths; 120mg/5ml or 250mg/10ml. Always check which strength is required as 10ml of the stronger Calpol contains twice as much paracetamol as 10ml of the weaker Calpol. The doses are always on the bottle/container label but check that they are in the correct box.
  • Calpol or paracetamol is given four hourly if required. This means that you cannot give another dose until at least four hours after the previous dose, e.g. if one dose was given at 10.30am, another dose cannot be given until 2.30pm. This is true of all forms of paracetamol (tablets, Calpol, suppositories). No more than four doses may be given in any 24-hour period.


For example:

  • If first dose given 10.30am;
  • Second dose given 2.30pm;
  • Third dose given 6.30pm; and
  • Fourth dose given 10.30pm.
  • No more may be given until 10.30am the following day, unless on specific instructions of a doctor.


  1. This information should be recorded on the PRN record sheet.


  1. Remember some cold and flu preparations contain paracetamol and must not be given if paracetamol has already been given.


  1. It is recommended that one person take responsibility for writing the medication charts as appropriate. Ideally this should be a senior member of staff. However, all therapy and support staff should be able to undertake this task. Training is to be provided if necessary.


  1. The hand written MARS forms are a potential source of error in transcriptions and therefore, the task should be limited by:


  • Using a chart for no longer periods than a month- 6 weeks.


  • When charts are written, they should be checked by a second person. Contrary to the advice concerning medicine administrations, this is a task that does require input by two staff members. All writing should be clear and legible.


  • Completed medication charts must be filed on the client’s file and retained for six years after the client no longer uses the service or dies.









  1. Some clients may need to administer medication themselves i.e. asthma pumps or insulin. They may choose to do this. In all cases of self-medication, it is essential that a risk assessment is carried out, at point of referral, to ascertain the ability of the client to self-medicate and to identify and eliminate any risk to themselves or to others. The record of the risk assessment is to be kept on the client’s file.


  1. Medication administered by the client must be kept in a lockable facility. Clients must be supported to understand that the safe storage of medication is for their own and other’s safety. One way is to have a small lock up box and put it in a cupboard or have a lockable drawer in their room. To prevent confusion it may also be useful to have an identifiable label specific to that client e.g. name and/or pictograph. If a client does not lock away his/her medication but still wants to keep the medication himself this must be subject to a separate risk assessment and advice sought from Serenity Health Operations Manager if required.


  1. Also, when medication is self-administered, agreement needs to be made with the client that they will take responsibility over the administration and storage of their own medication. This should be in writing. Ideally, the client must be supervised, but in all circumstances managers must monitor if clients are self-medicating correctly.


  1. It is essential that all staff but particularly Managers, are aware of clients who are self-administering medication and it is advisable that the situation be monitored on a regular basis and reviewed.


  1. It is unreasonable to expect a client to sign that he/she has taken medicines. It is more appropriate for staff to record details of stages of supporting self-medication. Staff keeping a record of medicines supplied to the client can successfully maintain the compliance with medication regimes. This can be maintained either when the client requests further supply or by auditing the remaining supply at a given time.


  1. Drugs record sheet must be initiated to confirm that medication has been taken.



Blood level checks


  1. For clients in residential units, on constant medication, blood levels and medication may need to be checked regularly. However, only a few medications actually need blood level checks. Managers need to ensure that they know which medications these refer to. This has to be done by a GP but it is the unit manager’s responsibility to ensure that these checks are carried out.






  1. Unit managers are responsible for ensuring that staff training is reviewed each year. Training needs to identify safe limits and possible side effects amongst other issues. New staff should receive training as soon as possible. All staff should receive training at least three yearly.


  1. In each unit a directory needs to be kept on medication and important issues e.g. MIMMS. If one does not exist in your unit then seek permission from Operations Manager for one to be purchased.


  1. The role of supervision is important and managers should cover administration of medication in supervision sessions. This is not only when they have concerns about individual members of staff but also for staff to raise concerns about medication.







  1. Some clients are on different types of medication and it is essential that staff know about this. It is essential that they know this information from the initial risk assessment in case advice at any stage has to be sought from GP and other medical practitioners. This information therefore needs updating by contacting the client’s GP.





Verbal Instructions on Medication



  1. If it is necessary to accept changes of medication over the telephone then request the relevant person e.g. GP or pharmacist to record the change on the MARS sheet. If advice is given over the telephone then ask for it to be faxed and suggest this is done within 24 hours. If this is not possible then try to get two staff to hear in order to verify and then write on the MARS sheet. If the GP or Pharmacist will not comply then refer with Manager for letter to be sent to explain the reason for this request.


  1. It needs to be pointed out that failure to comply with these procedures could result in work performance procedures being initiated in relation to the staff member concerned.


  1. Any concerns by managers and members of staff should be brought to their line manager’s attention immediately. Procedures are to be reviewed every six months.




Administration and Storage of Medication

Prepared by: 

The Management Team

Issue/review date:

January 2018

Review date:   

July 201


Approved by – Care Home Manager



January 28, 2018


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