Guidance on medicines administration by care assistants in nursing homes

Introduction

Older people in care homes are among the most vulnerable members of our society. Their medical and support needs are increasingly complex: most care home residents are aged >85 years and have multiple comorbidities – such as dementia and frailty (Office for National Statistics, 2014; British Geriatrics Society, 2011). Most rely on staff to meet many of their everyday needs, including taking prescribed medicines (Centre for Policy on Ageing, 2012).

Research has highlighted the importance of adopting appropriate medication procedures in care homes (Alldred et al, 2009). To reduce the risk of harm associated with medicine administration, it is recommended that care home staff undertake appropriate training and development, and care home providers are clear on staff’s roles and responsibilities (National Care Forum, 2013; 2011).

The National Institute for Health and Care Excellence (2014) has published guidance on all aspects of managing medicines in care homes. However, the role of healthcare assistants in administering medicines to residents of care homes with nursing (referred to here as nursing homes) is poorly articulated, and whether they should undertake this task has been raised by care home managers and staff. Often the concern is whether this is legal, or appropriate, if there is a registered nurse in the home.

Developing guidance

At the request of the Department of Health’s Care Sector Nursing Taskforce, we developed evidence-based guidance on whether, and in what circumstances, HCAs can administer medicines to residents of nursing homes. Our aims were to:

• Identify and appraise the literature on the administration of medicines by HCAs in nursing homes, focusing on safety, training needs and processes;
• Consider the context for the administration of medicines by HCAs in nursing homes by reviewing relevant legislation and policy documents;
• Produce a guidance leaflet for the sector.

We conducted a ‘rapid review’ (Ganann et al, 2010) of the literature on medicines administration by HCAs in nursing homes for older people, as well as of relevant legislation and policy documents. Our framework for conducting the review ensured the methods employed were rigorous and transparent (Centre for Reviews and Dissemination, 2001). Our inclusion criteria are detailed in Box 1. The review included 32 UK sources: nine research papers and 23 other sources of evidence (Table 1). Content analysis – as outlined by Pope et al (2007) – was used to synthesise the findings.

The salient points from our evidence-based guidance are summarised in Box 2 and detailed below. The full guidance (DH, 2016), as well as a full report of our methods and findings (Spilsbury et al, 2016), are available. The guidance draws attention to relevant legislation, policy and previous guidelines that set out good practice measures to safely manage and handle medicines in the nursing home sector; it should be read in conjunction with these.

Current regulations

HCAs are not prohibited from administering medicines to residents in nursing homes. The management and administration of medicines in care homes is covered by the Health and Social Care Act 2008 (Regulated Activities), and regulated by the Care Quality Commission, which has also produced guidance for providers (CQC, 2015). The regulations do not detail the nature of staff training, competence assessment or review frequency, but this is addressed in some of the literature and will be discussed later in this article.

Residents’ rights

An important starting point is to acknow-ledge that, first and foremost, residents in nursing homes (unless detained under the Mental Health Act 1983 or lacking mental capacity) have the same rights to choose to manage their own medicines, including the right to refuse them, as people living in their own home or in residential care homes (NHS Yorkshire and Humber Commissioning Support, 2015; NICE, 2015; CPA, 2012). Medicines management sits in the context of person-centred care, human rights and mental capacity legislation.

Responsibilities of RNs

Each RN is individually accountable for making sure all medicines are administered correctly and is personally accountable for up-to-date practice (Nursing and Midwifery Council, 2007). The RN can decide to delegate medicines administration to an HCA and, if doing so, must be confident the HCA is competent to undertake the task (RCN, 2017; NMC, 2007).

Education, training and assessment

The NMC is clear that, if medicines administration tasks are to be delegated to an HCA, that HCA must receive education,  training and assessment, which should be reviewed and recorded periodically (NMC, 2007; Royal Pharmaceutical Society of Great Britain, 2007). The importance of training is highlighted across the examined literature. As a minimum, training should cover:

• Supply, storage and disposal of medicines;
• Safe administration of medicines;
• Quality assurance and record keeping;
• Accountability, responsibility and confidentiality (RPSGB, 2007).

Role of care assistants

The RN must apply the principles of the administration of medicinal products (NMC, 2007) and may then ask an HCA to help the patient ingest or apply the medicinal product. Any HCA accepting the delegated task must take responsibility for ensuring their actions are carried out carefully, safely and correctly (CQC, 2015; Health, Social Care and Housing Committee, 2015). This extends to controlled drugs where an HCA can, at the request of the RN, be a second signatory but should witness the whole administration process, or can administer the controlled drug and help the resident ingest it under the RN’s direct supervision (NMC, 2007).

What can HCAs administer?

HCAs should only administer medicines they have been trained, and are competent, to give. There is no guidance on which medicines they can administer in nursing homes. In care homes without nursing (that is, residential care homes), these will generally include:

• Tablets, capsules or oral mixtures;
• Medicated creams or ointments;
• Ear, nose or eye drops;
• Inhaled medication (RPSGB, 2007).

It could be inferred that, in nursing homes, HCAs could help RNs administer the same medicines, as long as the care home provider has ensured appropriate training and assessment of competence.

Administering medicines using invasive or specialised techniques will normally involve an RN who has received up-to-date training (NHS Yorkshire and Humber Commissioning Support, 2015). Medicines HCAs should not normally administer in care homes include:

• Medicines administered via the rectum, for example suppositories, diazepam (for epileptic seizures);
• Injectable drugs such as insulin;
• Medicines administered through a gastrostomy, for example, a percutaneous endoscopic gastrostomy or jejunostomy;
• Oxygen.

In residential care homes, senior HCAs can have extra training in these administration methods to support resident care (NMC, 2007). In nursing homes, service providers could decide whether to give senior HCAs the same level of training.

The literature does not address HCAs administering drugs that require titration, such as warfarin, and it is unclear whether monitored dosage systems or technology-based solutions are inherently safer than administering medicines from manufacturers’ original packaging (Szczepura et al, 2011; Wild D et al, 2011; Barber et al, 2009). However, other common issues associated with drug administration errors are highlighted, which are detailed below.

Role of care home providers

Care home providers have a key role in ensuring policies and procedures for medicines administration are in place. These should be in line with current legislation and guidance, and address:

• Supply and ordering;
• Storage, dispensing and preparation;
• Administration;
• Disposal;
• Record keeping (CQC, 2015).

HCAs’ roles and responsibilities in medicine administration should be clear in these policies. In addition, service providers should ensure systems are in place that support their staff to report incidents and encourage a learning culture (RPSGB, 2007). The importance of policies, procedures and processes for safe medicine administration in care homes is highlighted across the examined literature.

Common issues

Several common issues associated with medicine administration errors were highlighted and should inform HCAs’ training and heighten their awareness, including:

• Incorrect crushing or cutting of medication;
• Not supervising medicines intake, particularly for residents with dementia;
• Incorrect timing;
• Omissions due to medicines not being available;
• Wrong drug or wrong dose (CPA, 2012).

Inhalers and liquid medicines are much more likely to give rise to medication errors than tablets or capsules (CPA, 2012; Alldred et al, 2011). Antibiotics may be particularly prone to errors, and missing doses can jeopardise treatment (CPA, 2012). It has also been observed that errors are more common in the morning because there are more interruptions during the preparation and administration of medicines (CPA, 2012). Systems must also be in place to ensure staff administering medicines check for allergies or sensitivities, and know how important these checks are to reduce the risk of harm.

The literature does not say anything about training HCAs in understanding prescription dose ranges. Ensuring the correct dose is administered is crucial, whether administration is done by an RN or HCA. Accountability for this rests with the delegating RN but delegation and accountability need to be well understood by RNs and HCAs.

Conclusion

There is a workforce crisis in the care home sector. Freeing up RNs’ time is a priority for providers, practitioners and policy makers. The DH (2016) guidance gives nursing homes an opportunity to rethink their staff’s roles and responsibilities, with the aim of improving how they deploy staff while enhancing care and providing timely, effective and safe medicines administration. Delegating medicine administration tasks to HCAs requires investing in training to ensure staff have the necessary knowledge, skills and competences.

• Our guidance does not translate to medicine administration by HCAs working in environments other than nursing homes.