pharmacists working in care homes

Ultimate guide

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We know too many care home residents are not getting the best from their medicines or are taking medicines which are doing them more harm than good and may be reducing their quality of life. Care home residents should receive the right medicines at the right time and in the right way to maximise the benefits of the medication. Pharmacists have the expertise to help achieve this and as part of a multidisciplinary team can be responsible for a whole system of medicines and their use within a care home.

We have developed this ultimate guide offering practical support and comprehensive signposting to help pharmacists who are already working in/with care homes or are interested in starting this new role.

By using this guide you will learn about the different roles pharmacists have in providing care to residents in care homes and the support tools and guidance that are available to help with the role.

The information below will provide you with a better understanding of the importance of the role of pharmacists in the care of residents in care homes.

Background

Great Britain Great Britain

General Pharmaceutical Council (GPhC) report on pharmacy and care homes

The independent report Pharmacy and Care Homes (December 2015) identifies a number of issues relating to safe medicines management in care homes including prescribing, dispensing, administration of and monitoring medicines. 
Recommendations include:

  • A stronger more integrated role for pharmacy professionals in care homes is needed along with a stronger relationship between the care home, community pharmacy and GP
  • Medicines management could be improved through appropriate staff training and more effective use of the medicines review process
  • Better systems need to be in place to share clinical data between settings and health professionals.

England England

Our policy and campaigns

The RPS believes it is time to change the way medicines are used in care homes. Our report, The Right Medicine: Improving Care in Care Homes (February 2016), provides the following recommendations:

  • Pharmacists should have overall responsibility for medicines and their use in care homes
  • One pharmacist and one general practitioner should be responsible for medicines in each care home ensuring coordinated and consistently high standards of care
  • Where a care home specialises e.g. in dementia care, the pharmacist should ensure they are competent to support the relevant clinical speciality
  • Local commissioners (such as Clinical Commissioning Groups or NHS England) should commission pharmacists to provide medicine reviews within care homes
  • Pharmacists should lead a programme of regular medicine reviews and staff training, working in an integrated team with other healthcare practitioners ensuring medicines safety.

View our policy briefing and further resources »

NHS England Five Year Forward View

The NHS Five Year Forward View was published on 23 October 2014 and sets out a new shared vision for the future of the NHS based around the new models of care. In January 2015, the NHS invited individual organisations and partnerships to apply to become ‘vanguard’ sites for the new care models programme. NHS England has stated “Each vanguard site will take a lead on the development of new care models which will act as the blueprints for the NHS moving forward and the inspiration to the rest of the health and care system”.

Information on the six enhanced health in care home vanguards which will offer older people better, joined up health, care and rehabilitation services can be viewed on the NHS England website.

Providers have produced factsheets to help understanding of the vanguards. Information on care homes can be found on page 3 of the factsheets.

Community pharmacy reforms

In an open letter from the Department of Health discussing community pharmacy reforms, changes the Government would like to see include better integration pharmacy into the wider primary care and community health system – such as closer working with GP surgeries, care homes and urgent and emergency care departments. 
You can find further information on the propsed changes on our community pharmacy reforms hub.

The care home use of medicines study

The Care Homes Use of Medicines Study  (CHUMS) (2009) was designed firstly to establish the prevalence, types and underlying causes of medication errors in residential and nursing homes, and assess the ensuing harm.  Secondly, the findings were looked at to develop solutions to reduce the prevalence of error. The study suggests that in order to prevent errors, pharmacists should regularly review with residents their medicines and rationalise medication regimens to help care home staff minimise the risk of errors. One of the conclusions of the report is that ‘pharmacists should clinically review all residents and their medications for appropriateness at least 6 monthly intervals.’

Health Foundation's SHINE project: Improving medicine prescribing in care homes

The SHINE project developed a medication review process that allows patients in care homes and their family or carers, to be fully involved in decisions about their medicines, focussing on person-centred care.

This video, produced by The Health Foundation, explains how the care of elderly care home residents can be enhanced through medication reviews.

 

Scotland Scotland

Our policy and campaigns

RPS in Scotland calls for a pharmacist in every care home to ensure safe and appropriate use of medicines. The report Improving pharmaceutical care in care homes (March 2012) sets out a change in the pharmacists’ role in care homes with the below recommendations on how to improve the quality of pharmaceutical care for residents:

  • A dedicated role for pharmacists working in every care home providing pharmaceutical care such as medication reviews to improve pain management, falls and fracture prevention and end of life care
  • One community pharmacy and one GP practice aligned to each care home with service level agreements which ensure continuity of care and cultivate the quality therapeutic partnerships required to improve both care and effective team work
  • Better sharing of information between all health and social care professionals involved in patient care including hospital discharge information, allergies and test results
  • A move away from use of monitored dosage systems and towards original pack dispensing to free up pharmacist and pharmacy technician time to spend time on improving care

Prescription for Excellence

Prescription for Excellence: A Vision and Action Plan for the Right Pharmaceutical Care through Integrated Partnerships and Innovation (September 2013). The Scottish Government’s objective is that all patients, regardless of their age and setting of care, will receive high quality pharmaceutical care using the clinical skills of the pharmacist to their full potential.

Wales Wales

Our policy and campaigns

The RPS Wales care home policy, Improving Medicines Use for Care Home Residents (March 2016), outlines five key themes as areas for immediate support from the pharmacy team:

  • Polypharmacy
  • Antipsychotic prescribing
  • Safe transfer of information
  • Education, training and standards
  • Palliative care

Several recommendations under each of these five key themes are set out in the policy, which if implemented, will improve the care, safety and quality of medicines use for residents living in care homes.

Older people commissioner for Wales: A place to call home

Review into the Quality of Life and Care of Older People living in Care Homes in Wales (November 2014). Overall the review concluded too many older people living in care homes have an unacceptable quality of life and the view of what constitutes ‘acceptable’ needs to shift significantly.

Your Care, Your Medicines: Pharmacy at the heart of patient-centred care

The Your Care, Your Medicines: Pharmacy at the heart of patient-centred care report says patients with supported living needs, whether living independently in their own homes or in a care home setting, must benefit from access to the pharmacy team to help manage their medicines effectively and to maintain their health and wellbeing.

Making Prudent Healthcare happen

In 2013 the Bevan Commission published Simply Prudent Healthcare, which considered how Wales could make the most effective use of available resources to ensure high quality and consistent care across Wales. Following this paper, the Minister for Health and Social Services outlined his vision for Prudent Healthcare at the Welsh NHS Confederation Conference in January 2014, including a draft set of principles. Further information can be found on the Prudent Healthcare website.

Telehealth enabled medicines management for care home residents

Beacon Digital Health and its NHS sponsor Abertawe Bro Morgannwg University Health Board (ABMU) were awarded a grant through the Welsh Technology and Telehealth Fund (HTTF) to implement and evaluate a digital medicines management solution for care homes in South Wales. In summary, the project shows there are significant risks in the medicines management process in care homes combined with a considerable waste of resources relating to unused medicines. Many of the risks are reduced by implementing an electronic system and by enabling pharmacists to make pro-active and consistent interventions.

About the roles

In this section you will find descriptions of some of the roles pharmacists are involved in to provide care to care home residents and signposting to apply for current posts.

Please note: this is not an exhaustive list of all the roles and services provided (for example pharmacists working for the inspectorate may visit care homes as inspectors, pharmacist working in GP out of hours services may provide advice to care homes, pharmacists may work for companies specialising in clinical services (e.g. ICS), or work for Local Authorities and voluntary organisations that provide services to care homes. There may also be other roles which are locally commissioned (you may want to contact your local CCG or Health Board for further information on these roles).

It is important to be aware that all care homes are different and will vary in the type of support and skills that will be required from a pharmacist. It may be useful to find out about the type of care home you are interested in working with. For example, is it for older people, people with learning disability, a mental health rehabilitation, supported living accommodation, providing personal care, providing nursing care, etc. Depending on this and other factors, the level of support needed from a pharmacist will be different which, will have an impact on the required qualifications, the competency and training or support tools you will need to perform your role.

It's vital to remember that when working in a care home, residents are keen to get to know the pharmacist and may want to know more about their treatment and managing their own medicines, so it's important you're prepared for this.

Some of the descriptions within the roles listed below may overlap so you might find it useful to look at all the role descriptions in this guide to obtain a better understanding of them.

Signposting to guidance and tools which can support you in the roles described can also be found in this guide

Working in a care home or a group of care homes Working in a care home or a group of care homes

Pharmacists can be employed by a care home or a group of care homes. They would be required to work with care home staff, GPs, community pharmacists and other healthcare professionals to effectively manage and optimise medicines use in the care home(s).

Responsibilities may include (please note this is not an exhaustive list):

  • Provide expert advice on medicines and their effective use to residents, care home staff and prescribers
  • Support the delivery of safe, clinically effective and cost effective prescribing (includes working with other healthcare professionals involved in the care of residents at the care home(s) e.g. GPs, community pharmacist, physiotherapists, etc.)
  • To develop , support and deliver training for care home staff on medicines management
  • Minimise waste of medicines
  • Regularly conduct clinical medication reviews (level 3 face to face) with residents, optimising the use of medicines and reducing the harm that can be caused by inappropriate use of medicines. May involve developing clinical management plans for the residents and discussion with a wider multidisciplinary group of health and social care professionals
  • Involved in writing, implementing and reviewing medicines policies/guidelines/protocols
  • Support care home staff with dealing with complaints and investigations relating to medicines management (e.g. social care, CQC, etc.)
  • Liaise with other healthcare professionals and teams to ensure seamless transfer of care
  • To undertake audits or research projects
  • Run regular clinics (for example polypharmacy, anticoagulation monitoring clinics, etc.)
  • Support patients with the management of long term conditions
  • Reduce inappropriate polypharmacy
  • Prescribe medication to residents as an independent prescriber
  • Support the residents in managing their medicines
  • Highlighting potential safeguarding issues with regard to medicines including the inappropriate use of covert administration
  • Be involved in the resident’s end of life care.

Working in care homes on behalf of a CCG/Health Board Working in care homes on behalf of a CCG/Health Board

You may be a lead pharmacist or a part of a team of healthcare professionals or pharmacists (e.g. Care Home Support Teams) responsible for the delivery of pharmacy services to all care homes in your CCG/HB area.

Responsibilities may include those outlined in Pharmacist working in a care home or a group of care homes above.

Additional responsibilities may include:

  • To improve cost effectiveness of prescribing and medicines use in care homes and provide specialist advice to GPs, nurses, and other healthcare professionals on the use of medicines
  • Be involved in the development and implementation of a medicines management strategy
  • Responsible for co-ordinating and implementing a range of prescribing support services to care homes
  • Development of locally commissioned services
  • Provide advice to safeguarding panels.

Working in a community pharmacy that provides services to care homes Working in a community pharmacy that provides services to care homes

Pharmacists and pharmacy teams working in community pharmacy can provide a range of services to care homes, and work closely with care home staff, care home pharmacists, GPs and other healthcare professionals to support residents in care homes.

Responsibilities may include (please note this is not an exhaustive list):

  • Safely dispense and supply both prescribed and non-prescribed medicines (including any changes in medicines prescribed during treatment)
  • Deliver medicines optimisation and clinical support services such as medication reviews
  • Provide public health services such as the administration of flu vaccinations to care home residents and staff
  • Provide expert advice on medicines and its use to residents and care homes staff (including use, storage, administration, etc)
  • Work with care homes staff and other healthcare professionals to ensure the appropriate provision of medicines for residents and to support optimal care. For example, the community pharmacist could identify that a clinical medication review is needed and discuss this with the pharmacist at the care home
  • Support residents in managing their own medicines where appropriate (for example using compliance aids)
  • Advise on cost effective prescribing and minimising medicines waste
  • Provide expert advice and support to care homes on meeting regulatory requirements (e.g from CQC, Care Inspectorate, Care and Social Services Inspectorate Wales etc)
  • Provide training to care home staff to support their role in medicines management
  • Provide medicines waste collection service.

(Please note: Pharmacists working in community pharmacy currently provide a range of medicines services to support with medicines optimisation such as Medicines Use Review, Discharge Medicines Review and the New Medicine Service. These services offers patients the opportunity to discuss their medicines to help them understand why the medicines have been prescribed as well as an opportunity to discuss and work to solve any problems they may be experiencing).

Although not currently available for care home residents, certain elements of these services would be beneficial and has the potential to be developed into a new service model for care home medication reviews. In future, the role of a pharmacist working in a community pharmacy with care homes is likely to expand, which is a focus within the community pharmacy reforms.

See below links for further information on nationally and locally agreed community pharmacy services to care homes:

The RPS has designed an online community pharmacist support hub  to provide easy access to our suite of resources, mapped over four themes to support day to day practice and to empower professional, confident pharmacy practice.

GP practice pharmacists providing services to care homes GP practice pharmacists providing services to care homes

The RPS has developed an online ultimate guide to support pharmacists working in or with GP practices

A pharmacist working in a GP surgery may also work with the care home(s) supporting them as described in the section above, Pharmacist working in a care home or a group of care homes

GP practice and primary care based pharmacists currently carry out a range of activities in care homes in some areas of Wales and England (the service could be locally commissioned). Pharmacists conduct clinical medication reviews with access to the GP Record. These reviews can be conducted in the care home with the carer or resident or with a named GP. As part of the multidisciplinary team, pharmacists use their expertise to take a broader view of the suitability of individual medication regimens and any monitoring which may be required.

GP led enhanced services to care homes are available in some areas of Wales and Scotland to assess and review the health of residents. This service includes regular medication reviews and promotes multidisciplinary team working.

In Wales, there may be Cluster Pharmacists working within a GP cluster who also work in care homes.

Pharmacists working for NHS 111 and NHS 24 Pharmacists working for NHS 111 and NHS 24

Pharmacists working in NHS 111 (England) and NHS 24 (Scotland) deal with out of hours queries from care home staff. NHS 111 and NHS 24 are 24-hour telephone based health services.

Examples of queries that NHS 111 receive from care homes can include:
  • missed medication,
  • drug interactions,
  • dosage,
  • incorrect drugs administered,
  • toxic ingestion,
  • accidental overdose,
  • advice on homely remedies,
  • situations when medication has not been delivered.
Pharmacists working in NHS 111 have read-only access to the patient’s summary care records (SCR) and the out of hours Special Patients Notes, which will include end of life care information.

Within NHS 24, pharmacists can view Emergency Care Summary (ECS) and any other useful uploaded information to help with the enquiries from care homes. Examples of enquiries can include:

  • obtaining medicines using the community pharmacy network (e.g. for new patients, previously ordered medications for existing residents that may have not been delivered, etc.),
  • advise on medication errors,
  • advise on residents needing pain relief,
  • antibiotics, etc.

NHS 24 deal with all medication related enquiries out of hours.

Applying for jobs Applying for jobs

Vacancies for pharmacists working with(in) care homes are often advertised on the following websites:

You may also be able to enquire with your CCG/Health Board, local care home and local GP practices about any available posts.

Examples of pharmacists improving patient care in care homes Examples of pharmacists improving patient care in care homes

  • Pharmaceutical Journal article “The Care Homes Clinician
    The SHINE project demonstrated the value of pharmacist-led medication reviews in care homes, in this article, independent prescriber Carmel Copeland describes the impact she has made.
  • Pharmaceutical Journal article “Pharmacists offer a clinical service to vulnerable care home residents”
    An article looking at how pharmacists support care home residents.
  • List of shared examples from the NICE website (good examples in what is currently being done and its success).
  • Better care for care home residents vanguard
    East and North Herts Clinical Commissioning Group (CCG) is working with Hertfordshire County Council and the Hertfordshire Care Providers Association on an NHS England Care Homes (vanguard) project to provide planned, proactive and preventative support to elderly care home residents with complex care needs.
  • The Proactive Care Homes Project – Central London Community Healthcare NHS Trust & CLARHC.
    A multidisciplinary proactive care project started in December 2013 across Kensington and Chelsea and Hammersmith and Fulham. The project aims were to reduce medication errors, patient falls and prevent unexpected hospital admissions. A total of 981 patients were seen in 11 months, with 6414 interventions made by the pharmacist, with a cost saving of £168,661. The key outcomes of the project included a reduction of falls by 35% and a 26% reduction in London Ambulance Service callouts from falls.

Practical guidance

Consultation skills Consultation skills

It is important to remember care home residents are keen to get to know the pharmacist and other team members looking after them, they do not want to be seen as a series of tasks but rather as an individual.

The Consultation Skills for Pharmacy Practice website has been developed to support pharmacists when speaking and consulting with people about their medicines and lifestyle choices.

The practice standards for consultation skills (March 2014) set out the knowledge, skills, behaviours and attitudes pharmacists need when communicating and consulting with patients.

To support with the development of consultation skills CPPE have an e assessment Consultation skills for Pharmacy Practice and WCPPE (Wales) have also produced a Consultation skills learning programme.

For your interest, pharmacists will be taking an increasingly patient-facing role as they support medicines optimisation and the public health agenda. The RPS report Now or never: shaping pharmacy for the future (November 2013) outlines the need for pharmacy to be proactive in the delivery of patient care.

Information technology Information technology

Technology is being increasingly used in care homes, we are aware that several systems are currently under trial and the systems used can vary between the care homes. It is important to fully understand the system in use in the care home you are working in/with, you should highlight and address any risks to patient care that you become aware of. (Please note: some care homes may not have electronic systems in place, it is important with these situations you also understand how records are stored and used).

Please also see section above on Telehealth Enabled Medicines Management for Care Home Residents (Wales)

You may find the following detailed information on existing electronic prescription systems useful:

To improve the resident’s safety and provide effective and high quality care, with the patient consent, a pharmacist should have access to the patient’s clinical information.
Information on the current status of Electronic Health Records (EHR) for England, Scotland and Wales can be found on the Electronic Health Record page on the RPS website.

In September 2015 NHS England  commissioned the implementation of Summary Care Records (SCR) into community pharmacy. Widening access to health information to community pharmacy will enable safer, better and more accessible care, which is particularly important when a patient needs emergency or unplanned care, for example when patients require urgent access to repeat medication.

Health and Social Care Information Centre (HSCIC) has produced a factsheet for pharmacy professionals which includes the benefits for community pharmacy, training, consent, pharmacy use of summary care records, insurance and liability. This factsheet contains useful information on the consent from care home residents for community pharmacists to view the resident’s SCR. HSCIC have also produced information on how access to summary care records can help with emergency supply.

The RPS has produced guidance on using SCR and a decision tool for community pharmacists as a guide to pharmacists in England accessing a patient’s electronic SCR. We are currently campaigning for equivalent access for community pharmacists in Scotland and Wales and further guidance will be available when access to the Emergency Care Summary and Welsh GP record has been agreed.

Case Study 8, Information Technology solutions , Appendix 1 , RPS Wales Improving Medicines Use for Care Home Residents (March 2016)  shows an adoption of an electronic medicines management solution which benefitted both the pharmacy and care homes.

Pharmacist training other staff Pharmacist training other staff

You may be required to train other members of staff at the care home. You should be confident and competent to do this.  To understand their role better you may find it useful to discuss roles and responsibilities with the individual staff member and the care home manager.

We are aware that some care homes have trained carers or nurses to become champions in areas such as in nutrition, dementia, falls and fragility etc.
Section 1.17 of NICE guideline [SC1] Managing Medicines in care homes   (March 2014), provides guidance on training and competency of healthcare staff. This guidance states “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” .

The National Minimum Training Standards for Healthcare Support Workers and Adult Social Care Workers in England provides you with information on the level of training and knowledge of a care home worker.

The Social Care Institute for Excellence (SCIE) provides training courses which may be useful to staff to help develop their knowledge and skills.
CPPE have developed an e-learning pack on Care Homes: Supporting people, optimising medicines. It will help update your knowledge about working with care homes, the roles and responsibilities of the teams involved and the legal issues, guidance and regulations surrounding medicines in care homes.

Skills for Care, Health Education England and Skills for Health jointly developed The Care Certificate which is a set of standards that social care and health workers stick to in their daily working life. It is the new minimum standards that should be covered as part of induction training of new care workers.

Health Boards in Wales can be contacted for information on whether they provide accredited training for care workers. New training standards are being developed for Wales’ healthcare support workers, information on this can be viewed on the Health in Wales website.

RPS accredited training and development materials might be useful for yourself and training others. We have also created mentoring support tools to help train and mentor colleagues.

Department of Health and University of Leeds guidance Administration of medicines in care homes (with nursing) for older people by care assistants (April 2016) provides information for care home providers, managers and staff about giving out prescribed medicines and the safety and quality requirements.

Indemnity and insurance Indemnity and insurance

It is a regulatory requirement for all registered pharmacists to "make sure that all your work, or work that you are responsible for, is covered by appropriate professional indemnity insurance".

The GPhC website contains information on professional indemnity requirements.

It is important you have the appropriate indemnity cover for the work you are doing with the care homes.

The RPS is not regulated by the Financial Conduct Authority and cannot recommend professional indemnity insurance providers, however NHS employers have published guidance and a series of questions and answers regarding professional indemnity insurance.

We recommend you discuss your liability and indemnity arrangements with your employer (e.g. care home owner, CCG/HB, community pharmacy, etc) for the services you are providing in care homes.

Audit Audit

Clinical audit is vital; first and foremost for patient care and safety, and additionally for the development and improvement of your professional practice. As part of your role you may be required to carry out audits in the care home you are working in. We understand the audits could be on activities such as the care home systems for managing medicines, quality of service the pharmacist/pharmacy is providing, etc.

NICE have produced a baseline assessment tool. This tool can be used by organisations to evaluate whether the care home practice is in line with the recommendations in the NICE guidelines [SC1] Managing Medicines in care homes (March 2014). It can also help organisations to plan activity to meet the recommendations.

Our Clinical Audit resource contains guidance and tools to help you conduct audits.

NHS National Institute for Health Research has published a Toolkit for care home research containing useful information and resources for those wanting to conduct or support research in care homes.

Quality improvement Quality improvement

The RPS has launched a quality systems resource for pharmacy. Its purpose is to introduce quality systems and quality improvement, acting as a hub to the fantastic improvement resources of others, and as a platform for sharing pharmacy experiences in quality improvement.

You may want to familiarise yourself with this resource as it will help you, your team or organisation improve their quality system leading to better workplace culture and quality of care.

Responding to medicines-related questions in practice Responding to medicines-related questions in practice

Pharmacists will need to respond to requests for information on medicines from colleagues and residents.

CPPE, NES and WCPPE, together with UKMI, have produced learning programmes to support pharmacists responding to medicines-related questions.

Professional guidance and ethical issues

Consent and confidentiality Consent and confidentiality

The need to protect patient confidentiality and obtain patient consent is layered through legislation, regulation and contractual frameworks.
Registered pharmacists need to be aware of GPhC regulatory guidance for consent and confidentiality:

Health and Social Care Information Centre (HSCIC)  have published a Guide to confidentiality in Health and Social Care . This guide has been issued to provide advice and guidance on any matter relating to the collection, analysis, publication or other dissemination of information. 

With regards to consent and care homes you may want to consider whether you have the consent:

  • needed to have access to GP practice (medical notes)
  • to speak to residents who are able and willing to do so
  • to communicate with family or representative
  • to share information from the resident and/or care home.

Section 1.2 of NICE guidelines [SC1] Managing Medicines in care homes (March 2014)  provides guidance on supporting residents to make informed decisions and recording these decisions.
The Department of Health published the Reference guide to consent for examination or treatment (second edition), this is a guide to the legal framework that health professionals need to take account of in obtaining valid consent to examination, treatment or care.

Standards on consent and confidentiality for nurses who are working with you at the care home can be viewed in The Nursing and Midwifery Council (NMC) The Code: Standards of conduct, performance and ethics for nurses and midwives.

Please refer to the section on the Mental Capacity Act-Deprivation of Liberty Standards Safeguard Care Act and the Adults with Incapacity (Scotland) Act (2000) for signposting to resources to help when a resident does not have the capacity to give consent.

You may also find it useful to have a look at the resources in the Safeguarding section of this guide.

Safeguarding Safeguarding

The RPS has developed quick reference guides on Protecting vulnerable adults and Protecting children and young people.

CPPE has developed learning packs on safeguarding.

NHS Education for Scotland (NES, Scotland)  has published Respecting and Protecting Adults at Risk in Scotland – legislation and practice An Educational Resource.

WCPPE (Wales) have produced learning modules on Protection of Vulnerable Adults , Safeguarding children and young people- Level 1 interactive and Safeguarding children and young people- Level 2.

Social Care Institute for Excellence (SCIE) have useful information, including e-learning, on their website  on safeguarding adults and children.

Information on CQC’s role in Safeguarding People (England) can be found on their website.

Raising concerns Raising concerns

The GPhC has published guidance on Raising Concerns (February 2012)  for all pharmacy registrants, it provides guidance on standards 1.2, 2.4 and 7.11 of the standards of conduct, ethics and performance. The document gives guidance to pharmacy professionals on how to raise concerns, explains the importance of raising concerns and the steps that a pharmacy professional will need to consider taking when raising a concern.

It is important for you and other care home staff to differentiate between complaints and concerns that should be raised/reported to regulatory bodies or is an issue that would be investigated internally within the care home. For example concerns regarding over ordering medicines is something that can be investigated internally. Some concerns may require you to contact and discuss with local CCG/HB Quality and Safeguarding team where relevant.

The following are resources that may be useful to you and other care home staff when raising/reporting concerns to regulatory bodies:

(Information on these bodies and the standards for care homes can be found in resources in the section Legal and Regulatory Framework).

The RPS has published the following resources for pharmacists on whistleblowing:

The CQC’s Orchid View serious case review can be viewed on their website. (Please note pharmacists are encouraged to raise awareness of the Orchid View case review with colleagues and teams, and to revisit their own “Whistleblowing” policies and procedures to ensure that concerns, including patient safety concerns are raised early).

You may want to refer to the “Safeguarding” section in CPPE’S e-learning programme Care Homes: Supporting people, optimising medicines  for a case study on raising concerns Orchid View Nursing Home. The case study looks at how you might raise a concern once an issue has been identified in the care home and the processes you could follow.

Working with a multi-disciplinary team Working with a multi-disciplinary team

Pharmacists working in/with care homes will work with other healthcare professionals as part of a multi-disciplinary team. This may also involve training or mentoring multi-disciplinary colleagues, in medicines management (for further details on training see section in this guide on Pharmacist training other staff).

We have developed a leadership framework and tools which includes a section on engaging your team which may be helpful.

Pharmacists will be required to work closely with nurses in care homes. The NMC has developed standards on medicines management for registered nurses.

Other resources which may be useful include:

In December 2014, the Royal College of Nursing and the Royal Pharmaceutical Society discussed how the two professions could work together to help patients make the most of medicines. Following on from this, the we published a report. We have also worked together to create a 2nd report discussing how to work better across primary and community care from their joint summit in December 2015. The summit showcased different ways in which nurses and pharmacists are delivering care to different groups of patients and the purpose is to inspire pharmacists and nurses to make changes locally in the way that they work together to improve how patients use their medicines and the outcomes that they get from those medicines. Session 1 (p.4-5) looks at the work of a new and innovative team and how they have worked collaboratively with care homes with nursing to improve safety, quality of care and wellbeing of the patients. Consideration is also given to how the Nurse-Pharmacist relationship can be nurtured and developed to support these outcomes.

Managing and optimising medicines

Medicines reconciliation Medicines reconciliation

RPS believes that the “pharmacy team must lead the medicines reconciliation within the care home setting as part of the multidisciplinary team” (see The Right Medicine: Improving Care in Care Homes February 2016).

“Reconciliation of medicines should be undertaken by a pharmacist when a person moves to a care home or another care setting to ensure that their medication record is maintained accurately” (Improving Medicines Use for Care Home Residents March 2016).

NHS East and South East England Specialist Pharmacy Services have published a toolkit titled Medicines Reconciliation: Best Practice Resource and Toolkit   . It will help organisations evaluate the effectiveness of existing processes, identify and respond to any gaps in service provision and support improvements in current medicines reconciliation processes all with an aim to improve patient safety within the organisation.

Section 1.7 NICE Guidance Managing Medicines in Care Homes (March 2014) outlines guidance on medication reconciliation.

Clinical medication reviews Clinical medication reviews

The RPS believes “all residents should receive a review of their medication by a pharmacist when they first move into a care home in order to optimise their medication regime” (see Improving Medicines Use for Care Home Residents (March 2016). “Every care home resident should have a pharmacist led medicines review at least once a year or whenever a medicine is started, stopped or changed and when a resident moves between care settings” (see The Right Medicine: Improving Care in Care Homes (February 2016). (Please note it is also important that when a resident moves from one care home to another the information on their treatment and medicines is effectively communicated between the care home teams preventing delay and error in the resident’s care).

Pharmacists have an important role in conducting medication reviews assisting in supporting residents with their medicine use, reducing polypharmacy, improving compliance, reducing errors,  improving residents’ health & wellbeing and reducing waste.

Pharmacists working in care homes or with care homes should be able to provide a level 3 medication review. A level 1 medicines reconciliation review at each transfer of care should be considered as well.
Comprehensive information about medication review (including level 1 and 3) can be found in A guide to medication review 2008, published by the National Prescribing Centre. A table with the characteristics of the different types of medication reviews can be viewed on p.9. Within this guidance you may find it useful to have a look at Case study 4 Medication Reviews in Care Homes (p.18).

Pharmacists working in community pharmacy currently provide a range of medicines optimisation services such as Medicines Use Reviews, Discharge Medicines Review and the New Medicine Service. Although not currently available for care home residents, certain elements of these services would be beneficial and has the potential to be developed into a new service model for care home medication reviews. In future, the role of a pharmacist working in a community pharmacy with care homes is likely to expand, which is a focus within in the community pharmacy reforms (see section on Community Pharmacy Reforms above) .

You may also want to check with the local CCG/HB for any commissioning arrangements to provide medication reviews within the care homes in your area.

Section 1.8 NICE Guidance Managing Medicines in Care Homes (March 2014)  outlines guidance on medication reviews.

NICE guidance Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (March 2015) offers best practice advice on the care of all people who are using medicines and also those receiving suboptimal benefit from medicines.

NICE Quality Standard Medicines management in care homes (March 2015) covers the prescribing, handling and administering of medicines for all people (including adults, children and young people) living in care homes, and the provision of care or services relating to medicines to those people. Tools and resources to help implement this guidance can be accessed on the NICE website.

UKMI and NHS PrescQIPP have published information on Optimising Safe and Appropriate Medicines Use (June 2013) which you can use when speaking to residents about their medicines. 
video produced by The Health Foundation explains how the care of elderly care home residents can be enhanced through medication reviews.

The NHS Cumbria STOPP/START toolkit. Supporting medication review (February 2013) is based on the STOPP START Tool a medication review tool designed to identify medication where the risks outweigh the benefits in the elderly and vice versa.

The Abbey Pain Scale can be used for measuring pain in residents with dementia who cannot verbalise.

At Ealing Hospital, a pocket guide and handy mnemonic, “MAP”, are helping pharmacists to assess older people’s risk of falling when taking anticholinergic medicines.

An article in the BMJ provides information on using the NO TEARS tool for a medication review.

You may find the following case studies on medication reviews useful to read:

Polypharmacy Polypharmacy

Pharmacists have an important role to play in the reduction of inappropriate polypharmacy.

NHS Specialist Pharmacy Service Medicines Use and Safety have produced information on Seven steps to managing polypharmacy . This process has been created to assist with medication review and decisions around deprescribing in the context of polypharmacy and aims to address polypharmacy as part of overall medicines optimisation strategies. It can be used in successive consultations to address one or a small number of polypharmacy issues at a time.

PrescQIPP has produced a Polypharmacy & Deprescribing Webkit  which includes a range of information and resources. 

NHS Specialist Pharmacy Service Medicines Use and Safety has produced A patient centred approach to polypharmacy which you may want to use when discussing the resident’s medicines.

CPPE has produced a learning programme  to help develop your knowledge and skills in working with patients and other health and social care professionals to enable patients to get the best possible outcomes when they are taking multiple medicines.

The Scottish Government and NHS Scotland have produced a Polypharmacy guidance website based on the Scottish Government polypharmacy guidance (March 2015). The ‘7-steps’, defined within this guidance, aim provide a clear structure for the medicines review process, centred on  the needs of the individual as a whole, and encouraging the dialogue between clinician and patients to include non-pharmacological solutions as well as medication ones. This guidance aims to support those carrying out comprehensive face - to - face medication reviews with patients and where appropriate carers/welfare proxies. It also contains some information that patients will find useful.

The King’s Fund published a report on medicines optimisation and polypharmacy. Exploring systems for managing polypharmacy and offering recommendations for improving care for older people and those who have two or more chronic medical conditions.

WCPPE have produced a learning programme  to help pharmacy professionals understand the physiological changes that occur in the elderly and the impact of polypharmacy and reducing medicines wastage.

All Wales Medicines Strategy Group have produced Polypharmacy Guidance for Prescribing.

NHS Wales have developed guidance on Polypharmacy: Guidance for Prescribing in Frail Adults

The following case study on reducing polypharmacy by conducting a medication review may be useful to you. 
Case Study 2, Polypharmacy medicines review , Appendix 1 , RPS Wales Improving Medicines Use for Care Home Residents (March 2016) 

Medicines optimisation (England) Medicines optimisation (England)

You will have regular contact with residents in the care home and are therefore in a key position to spearhead patient centred approaches that enable the patient to obtain the best possible outcome from their medicine.

NICE guidelines describe medicines optimisation as “the safe and effective use of medicines to enable the best possible outcomes”.

The RPS has created a wide range of resources on medicines optimisation; including good practice guidance, a patient leaflet, and briefings on optimising medicines for a number of conditions.

NICE has also developed a medicines optimisation pathway, covering the decision making processes used to help optimise a person’s medicines; including medicines reconciliation and medication review.

NHS England has developed a Medicines Optimisation Dashboard England, which is designed to help further understand how patients are being supported with medicines use locally.

CPPE has produced the following e-learning programmes relating to medicine optimisation:

Pharmaceutical Care (Scotland) Pharmaceutical Care (Scotland)

Pharmaceutical Care is a person –centred philosophy and practice that aims to optimise the benefits of drug therapy and minimise the risk of drug therapy to patients by providing the framework for pharmacists to apply their knowledge and skills.

The Scottish Government has published the following two documents that may be of interest to you:

NHS Education for Scotland has produced a learning resource for the pharmaceutical care of people with dementia.

Pharmaceutical Care and Prudent Pharmacy (Wales) Pharmaceutical Care and Prudent Pharmacy (Wales)

Your Care, Your Medicines: Pharmacy at the heart of patient-centred careYour Care, Your Medicines: Pharmacy at the heart of patient-centred care presents a vision for pharmacy in Wales. The ambition is for patients in Wales to be put at the centre of their care, to benefit from the full integration of the pharmacy team into the NHS and to ensure every intervention involving medicines is supported, communicated and coordinated across the health and social care system.

Medicines adherence Medicines adherence

Poor medicines adherence can lead to hospital admissions and difficulty in managing conditions. 
Further information can be found in the RPS quick reference guide Medicines Adherence and NICE clinical guidelines on Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence.

Medicines waste Medicines waste

RPS believes if “pharmacists have responsibility for medicines use this will help solve the issue of medicines waste, improve efficiency and provide better health outcomes for residents” The Right Medicine: Improving Care in Care Homes February 2016) .

NHS PrescQIPP has developed information for prescribers and care home staff  on reducing medicines waste in care homes (April 2015). (Please note information from this website may be for those who have subscribed. You may want to discuss subscription arrangements with the care home or local CCG.)

NHS England published a report titled Pharmaceutical waste reduction in the NHS (June 2015), a number of opportunities are  identified that could assist in the reduction of therapeutic and material waste throughout the UK through focus on prescribing and dispensing methods, as well as targeting particular patient and drug types (see section 3.2 for care home case studies).

The NHS Lanarkshire Care Homes Protocol Group have produced a Care Home Prescriptions - Good Practice Guide outlining a robust system of ordering medicines with a reduction in waste.

The following case study shows a reduction in medicines wastage after reviewing the medicines ordering system:
Case Study 6, Training care home staff (ordering systems), Appendix 1, RPS Wales Improving Medicines Use for Care Home Residents (March 2016) 

Covert administration of medicines Covert administration of medicines

UKMI have published comprehensive information on What legal and pharmaceutical issues should be considered when administering medicines covertly? legal and pharmaceutical issues should be considered when administering medicines covertly?
NICE have produced Quality Statement 6: Covert medicines administration (March 2015). Adults who live in care homes and have been assessed as lacking capacity are only administered medicine covertly if a management plan is agreed after a best interests meeting.

CPPE workshop The Mental Capacity Act 2005 and covert administration of medicines aims to develop knowledge and skills to help manage and optimise care for patients who might lack mental capacity to make a specific decision relating to their medicines at a given point in time.

The Mental Welfare Commission for Scotland have published the Good Practice Guide Covert Medication  which applies to situations in which an individual lacks capacity to make a decision regarding medical treatment and refuses treatment.

Betsi Cadwaladr University Local Health Board (East) have published NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. (Please have a look at the guidance on the NEWT Guideline website on how to use the information obtained on each drug in practice).

The  Handbook of Drug Administration via Enteral Feeding Tubes, 3rd Edition (March 2015) Rebecca White and Vicky Bradnam, Pharmaceutical Press , covers the technical, practical and legal aspects that you should consider before prescribing or administering drugs via enteral feeding tubes. 

You may also find it useful to have a look at the section on Mental Capacity Act – Deprivation of Liberty Standards Safeguard Care Act within this guide.

Medicines Administration Records (MAR) charts Medicines Administration Records (MAR) charts

NICE guidelines Managing Medicines in care homes (March 2014) provides details on the use of Medicines Administration Records (MAR charts) in care homes.

Controlled drugs Controlled drugs

NICE guidance Controlled Drugs: Safe use and management (April 2016) covers systems and processes for using and managing controlled drugs safely in all NHS settings except care homes. It aims to improve working practices to comply with legislation and have robust governance arrangements. It also aims to reduce the safety risks associated with controlled drugs. The guideline is for:

  • Health professionals providing care for people being treated with controlled drugs, for example, GPs, pharmacists and nurses.
  • Social care practitioners, for example, home care workers, personal assistants and social workers.
  • Commissioners of services using controlled drugs, for example, local authorities and clinical commissioning groups.
  • Providers of services where controlled drugs are used, for example, substance misuse services, ambulance services, home care providers, community pharmacies, community health providers, GPs and other independent prescribers, dispensing doctors, voluntary agencies and charities.
  • People being treated with controlled drugs, their families or carers, and the public

Please note:  The above people or organisations may or may not provide care to people in care homes, but this guidance is still relevant to them if they are part of any system/process involving CDs. 
NICE Guidance Managing Medicines in Care Homes (March 2014)  provides useful guidance on managing controlled drugs in care homes.

Section 3.7 Medicines, Ethics and Practice (MEP), edition40, contains information on controlled drugs possession and supply, administration, requisitioning, safe custody and destruction.

Medication errors Medication errors

The care home should have procedures in place to investigate and report errors (both internally and externally for example to regulatory bodies (see below in this section for further information), CCGs/HBs).

The CCGs/HBs as part of their governance may have systems in place to report medication errors so that improvements can be made in the care homes.

We are aware that in care homes when a medication error occurs or it has been found out that one has been made, it is highlighted to the care home manager and also documented by the pharmacist (on reporting systems e.g. Datix) to be followed up and discussed at board meetings.

The Care Homes Use of Medicines Study  (CHUMS) (2009) outlines information on the types of medication errors, the causes and possible solutions.

NPSA have medication safety resources on their website. Guidance and access to resources to support root cause analysis investigations can be viewed on the NPSA website.

Section 1.5 of the NICE Guidance Managing Medicines in Care Homes (March 2014) provides guidance for care homes in identifying, reporting and reviewing medicines-related problems.  It highlights “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”.

Information on reporting events to the regulatory bodies can be found on the links below;

Drug alerts Drug alerts

The following will support you with information on drug withdrawals, medicine indications changes and alerts:

Multi-compartment compliance aids (MCAs) Multi-compartment compliance aids (MCAs)

The Royal Pharmaceutical Society has been working together with stakeholders to improve patient outcomes and patient-centred care with the better use of multi-compartment compliance aids (MCA), also known as monitored dosage systems (MDS).
It's important that the assessment and selection of intervention options to help maintain healthy independent living are patient-centred, therefore the use of MCA must not be regarded as a universal solution.

The document “The better use of multi-compartment compliance aids” (July 2013) can be downloaded from our dedicated MCA resource area, also you can view other key related documents impacting upon the best-use of MCAs and MDSs.

Clinical guidance and support tools

Antipsychotics Antipsychotics

The RPS believes that pharmacists should play a key role as part of the multidisciplinary team in providing oversight of psychotropic medicines prescribed in care homes to ensure it is kept to a minimum.

NICE Quality standard Psychosis and schizophrenia in adults (February 2015)  covers the treatment and management of psychosis and schizophrenia (including related psychotic disorders such as schizoaffective disorder, schizophreniform disorder and delusional disorder) in adults (18 years and older) with onset before the age of 60 years in primary, secondary and community care.

Royal College of Psychiatrists, National Audit of Schizophrenia (NAS) is an initiative of the Royal College of Psychiatrists' Centre for Quality Improvement (CCQI). Participating in NAS enabled clinicians who treat people with schizophrenia in the community to assess the quality of their prescribing of antipsychotic drugs and of their monitoring of patients’ physical health. It also supported them to monitor patients’ experience and outcome of treatment, plus carers’ satisfaction with information and support.

Case Study 1, Reviewing antipsychotic medicines , Appendix 1 , RPS Wales Improving Medicines Use for Care Home Residents (March 2016) 

The Maudsley: Prescribing Guidelines in Psychiatry 12th ed. Wiley-Blackwell: Chichester; 2012 provides clinicians with practically useful advice on the prescribing of psychotropic agents in commonly encountered clinical situations.

The Right Prescription: A Call to Action. Reducing the inappropriate use of antipsychotic drugs for people with dementia is a pack containing resources to support pharmacists and other healthcare professional to tackle the issue of inappropriate prescribing.

Dementia Dementia

It is important that if you are working with(in) a care home that specialises (e.g. dementia care) you should be satisfied you are competent to support with this speciality.

Social Care Institute for Excellence (SCIE) dementia hub contains supportive information and resources, including videos, e-learning material and downloads, for care workers, people living with dementia, and their friends and family. Some resources are mapped to the Qualifications and Credit Framework (QCF) units to support your learning.

CPPE Consulting with people living with Dementia (January 2016)  will help you consider what is different about consulting with people living with dementia and how you can prepare for and approach these consultations so that people get the most benefit from them.

Dementia Action Alliance (DDA) aims to bring about a society-wide response to dementia. It encourages and supports communities and organisations across England to take practical actions to enable people to live well with dementia and reduce the risk of costly crisis intervention.

NHS Education for Scotland: The pharmaceutical care of people with dementia meets the education and training needs of pharmacists and pharmacy technicians who deliver services to people with a diagnosis of dementia, their families and carers.

NHS Education for Scotland: Dementias webinar explores the symptoms, differential diagnosis, general management principles and appropriate treatment of the dementias and how the pharmacy team can contribute to good practice in the care of people with dementia.

Scottish Government: The Standards of Care for Dementia in Scotland (June 2011)  provides the framework for pharmacists to improve pharmaceutical care in this setting.

WCPPE: The pharmaceutical care of people with dementia.  meets the education and training needs of pharmacists and pharmacy technicians who deliver services to people with a diagnosis of dementia, their families and carers. It supports delivery of care that is evidenced based and current, while providing many additional sources of useful information

Dementia webinar on RPS website (March 2011) helps you to gain an understanding of different types of dementia and their presentations, with an introduction to cognitive enhancers and how these may affect other symptoms than just memory. You will also learn how to recognise adverse reactions, drug interactions and how to recommend treatment if appropriate as well as how to treat behavioural symptoms in people with dementia. In addition you will expand your knowledge on how to help with compliance and concomitant medication issues.

The Right Prescription: A Call to Action. Reducing the inappropriate use of antipsychotic drugs for people with dementia is a pack containing resources to support pharmacists and other healthcare professional to tackle the issue of inappropriate prescribing.

Quality care outcomes for individuals with dementia webinar on RPS website helps to raise awareness in the diagnosis and appropriate management of dementia and its associated psychological and behavioural symptoms. Also to promote an understanding of comfort and distress and where pharmacist in general can support care givers.

Information on dementia can also be found on the RCN website.

Depression Depression

Depression is often an under recognised condition and around 40% of people in care homes suffer from depression , Royal College of Psychiatrists: Depression in older people . Pharmacists who are interacting with residents / people in care homes and undertaking clinical medicine reviews should be aware of some of the following symptoms which can be indicative of depression. The person may:

  • withdraw into themselves
  • not eat and lose weight
  • not brighten up until the afternoon
  • not show signs of physical symptoms improving despite treatment, and have a preoccupation with this
  • say they wished they were dead
  • wake early in the morning e.g. at 4am where this is not normal for that person

CPPE has developed a programme to help pharmacists build your knowledge of the management of people with depression, and better understand the condition, its impact and approaches used to manage it.

NICE Quality standard [QS50] Mental wellbeing of older people in care homes, December 2013, covers the mental wellbeing of older people (65 years and over) receiving care in all care home settings, including residential and nursing accommodation, day care and respite care.

NICE guidelines [90] :Depression in adults Recognition and management (October 2009) covers identifying and managing depression in adults aged 18 years and older, in primary and secondary care. It aims to improve care for people with depression by promoting improved recognition and treatment.

You may also want to contact your CCG/HB to discuss any local guidance available on depression and supporting care home residents with it.

Diabetes Diabetes

Diabetes UK has published Good clinical practice guidelines for care home residents with diabetes (January 2010) , this document should provide a framework of assessment of the quality of diabetes care within care homes for use by regulatory bodies who have responsibility for this provision.

We have also published a Diabetes toolkit for our members.

International Diabetes Federation has published global guideline on Managing older people with type 2 diabetes . This Guideline has provided many examples of recommendations that are based on conclusive clinical trial evidence, e.g. in the areas of prevention, use of particular therapies, blood pressure and lipid regulation, and management of peripheral vascular disease and foot disorders. These provide additional reasons why good quality diabetes care is important in older people because they demonstrate similar benefits experienced by younger people from these interventions

Diagnostic interpretation of tests Diagnostic interpretation of tests

The RPS has published practice guidance for Diagnostic testing and screening services, which includes 10 principles of good practice.

You may be required to review pathology results for residents on known medicines. Pharmaceutical Press have published a clinical pharmacy practice resource ‘Pathology and therapeutics for pharmacists’ which can help pharmacists to understand these results.

Dysphagia Dysphagia

The Patients Association completed a Survey of medicines related care of residents with dysphagia in care homes (October 2015). It found as many as 50% of residents are affected by swallowing difficulties (dysphagia), which can make tablets difficult or even impossible to swallow.

National Patient Safety Agency (NPSA): Ensuring safer practice for adults with learning disabilities who have dysphagia (July 2007) guidance document aims to ensure safer practice for adults with learning disabilities who have difficulty in swallowing (dysphagia). It highlights best practice and provides resource materials to give practical help. The tools can be adapted for local use and for any adult who has dysphagia.

Betsi Cadwaladr University Local Health Board (East) has published NEWT Guidelines for the administration of medication to patients with enteral feeding tubes or swallowing difficulties. (Please have a look at the guidance on the NEWT Guideline website on how to use the information obtained on each drug in practice).

Scottish Intercollegiate Guidelines Network (SIGN): Management of patients with stroke: identification and management of dysphagia A national clinical guideline (June 2010) provides recommendations based on current evidence for best practice in the identification and management of dysphagia after stroke.

There are certain types of dosage form that should never be split or crushed. You may find it helpful to refer to RPS’ advice /clarification on crushing tablets and opening capsules (June 2011) and information on pharmaceutical issues when crushing, opening or splitting oral dosage forms (June 2011).  These document aims to highlight these dosage forms, the science behind why they should remain intact, and the possible consequences of splitting or crushing various dosage forms.

Prescribers and pharmacists both have a responsibility to ensure that where Specials are prescribed they are the most appropriate choice and patients are supported to use them effectively. RPS Guidance for prescribers of specials (June 2016)  along with the RPS Professional guidance for pharmacists on the procurement and supply of Specials (December 2015) will help to support the appropriate prescribing of Specials for patients.

End of life care End of life care

The RPS believes that “advice about, and access to, end of life medicines and anticipatory care medicines should be formalised between prescribers, pharmacists and care home providers “ The Right Medicine: Improving Care in Care Homes (February 2016).

NICE Guideline (NG31) Care of dying adults in the last days of life (December 2015) covers the clinical care of adults (18 years and over) who are dying during the last 2 to 3 days of life. It aims to improve end of life care for people in their last days of life by communicating respectfully and involving them, and the people important to them, in decisions and by maintaining their comfort and dignity. The guideline covers how to manage common symptoms without causing unacceptable side effects and maintain hydration in the last days of life.

To help care providers approach the planning process with confidence and knowledge, a team at the National End of Life Care Programme (NEoLCP) has developed an 'Advance Care Planning: It all ADSE up' toolkit.

You may also find it useful to have a look at the section on Mental Capacity Act – Deprivation of Liberty Standards Safeguard Care Act within this guide to consider consent from residents without capacity.

Useful information on End of Life care can also be found on the RCN website.

Falls and frailty Falls and frailty

RPS recommends that a resident must receive a falls assessment on admission into a care home and regularly thereafter, and a pharmacist should be involved in assessing falls risk from the medicines that the resident takes (see above for clinical medication review).

NICE guidelines (CG161) Falls in older people: Assessing risk and prevention (June 2013)  provides recommendations for the assessment and prevention of falls in older people. You can use the Multifactorial falls risk assessment within these guidelines to assess falls on admission to care homes.

The British Geriatrics Society (BGS) has launched the first of a two-part guidance on the recognition and management of older patients with frailty in community and outpatient settings called Fit for Frailty (June 2014).The guidance will help to recognise the condition of frailty and to increase understanding of the strategies available for managing it.

Clinical Knowledge Summaries (CKS): Falls risk assessment (January 2014)  covers the identification and management of the risk of falling in older people (65 years of age and older).

NHS Wales have developed guidance on Polypharmacy: Guidance for Prescribing in Frail Adults, it aims to provide guidance on how to make a safe and sensible decision in situations where extra thought and considerations are needed.

At Ealing Hospital, a pocket guide and handy mnemonic, “MAP”, are helping pharmacists to assess older people’s risk of falling when taking anticholinergic medicines.

Pharmacists may be interested to read an article about The Fraility Fulcrum (Dr Dawn Moody). The concept of frailty as a long-term condition brings with it the opportunity to adopt a much more proactive, person-centred, community-based approach to care. The ‘frailty fulcrum’ is an animated model for frailty that has been developed with these opportunities in mind.

Flu vaccinations Flu vaccinations

Vaccinations are the most effective method of protection against the flu. Pharmacists in England, Scotland and Wales have been providing flu vaccinations for many years now, through private and locally commissioned services.

For up to date information on the national seasonal influenza programmes and patient groups who are eligible to receive a vaccination on these programmes please visit our seasonal influenza hub, for updates and latest news.

If you're considering the professional aspects of setting up a private service for the administration of the flu vaccination via a patient group direction (PGD) in the care home you work in or are working in, see our Setting up a flu vaccination service via patient group direction guidance.

In England , there is now a national advance flu vaccination service delivered by community pharmacies. You can find out more about the advanced service on the PSNC website . (Please note: One of the eligible patient groups for the service is people living in long-stay residential care homes or other long-stay care facilities. The flu vaccination service must be provided on the pharmacy premises in the consultation room, but where a contractor has been asked to vaccinate people in a long-stay residential care home or other long-stay care facility, and the contractor agrees to vaccinate these patients, they may do this at the care home/facility if this is approved by the local NHS England team). You may also want to contact your local CCG or HB for information on locally commissioned flu vaccination services.

You may also want to contact your local CCG or HB for information on locally commissioned flu vaccination services.

The Immunisation against infectious disease (The Green Book) has the latest information on vaccines and vaccination procedures for all the vaccine preventable infectious diseases that may occur in the UK. You might also want to see updates to The Green Book.

Identifying and responding to adverse drug reactions Identifying & responding to ADRs

Pharmacists play a significant role in the identification and reporting of adverse drug reactions.

The Medicines and Healthcare Products Regulatory Agency (MHRA) has produced guidance on adverse drugs reactions, which includes a classification of adverse drug reactions.

HSCIC has produced information  on how access to summary care records can help reduce adverse reactions . 

Yellow Card Centre Scotland and NHS Education for Scotland have developed a learning resource about adverse drug reactions , their incidence and public health implications. It explains the different classifications of ADRs and drug allergies, how to identify if a patient is experiencing an ADR and subsequent management.

Minor ailments Minor ailments

Part of a role of a pharmacist working in or with care homes may be to advise on or treat minor ailments in residents.

RCGP has produced an e-learning programme for CPPE for the self-care for minor ailments. CPPE, NES and WCPPE have also produced a pack on responding to minor ailments.

The Safety of Medicines on Care Homes in partnership with the National Care Forums (NCF) has published a Homely remedies guide: for local adaptation to fit within individual care home medication policies which can be accessed via the NCF website.

PrescQIPP has produced a bulletin to help care homes set up a homely remedies system (login details are required).

WCPPE  has produced a distance learning pack which looks at the clinical management of minor ailments which frequently present in the pharmacy. All Wales Medicines Strategy Group has produced an All Wales Common Ailments Service Formulary.

NES  has produced a distance learning pack  on responding to minor ailments, learning resource on self-management to help healthcare workers develop knowledge and understanding to support self-management, and a resource on common clinical conditions and minor ailments. “The resource includes an overview of the most common clinical conditions (including signs, symptoms and alarm symptoms), and advice on how to respond to these conditions, be that through provision of advice or medication, or to refer to another profession or service.”

NHS Choices  is a useful website, providing health information in the form of articles, videos and tools for patients, pharmacists may choose to signpost residents to this if further information is requested. NHS Inform  is a health and care information service for people in Scotland.

Nutrition and hydration Nutrition and hydration

NHS England's Guidance – Commissioning Excellent Nutrition and Hydration 2015 – 2018 states Malnutrition is common in the UK, affecting more than three million people at any one time. Around 1 in 3 patients admitted to acute care will be malnourished or at risk of becoming so, and 35 percent of individuals admitted to care homes will also be affected. In addition 93 percent of those at risk of, or suffering, from malnutrition will be living in the community.”

The aim of the above guidance is to support commissioners to address these issues and develop strategies to improve the delivery and commissioning of excellent nutrition and hydration care in acute services and the community. Pharmacists will find it helpful to be aware of this report and consider the recommendations when conducting medicines reviews with residents in care homes.

Think Kidneys’ is a national programme led by NHS England in partnership with UK Renal Registry, providing useful information on acute kidney injury (AKI) and groups of patients at risk. There are resources containing information and training for managers and staff in care homes to help prevent, detect, treat and manage acute kidney injury.

The British Nutrition Foundation website has useful information on dehydration in elderly, which is a very common issue in care homes. You may also want to refer to their Healthy Hydration guide when speaking to residents.

The South Essex Partnership University NHS Foundation Trust (SEPT) Food First guidance is an example of nutritional support resource which you may find useful to use with residents in the care home.

The Royal College of Nursing also provide detailed information on nutrition and hydration.

Older people Older people

The type of care home you are working in or interested in may require you to support older people. The resources in this section may be of help to you in doing this.

NICE advice Older people in Care Homes (February 2015)   This briefing summarises NICE's key recommendations for local authorities and partner organisations on the health and care of older people in care homes. It also highlights relevant quality standards.

CPPE Older people (May 2015)  This learning programme is to update your knowledge on the changes that come with ageing and the impact these have on health and medicines use for older people. It looks at the management of polypharmacy and the pharmacy services that support medicines optimisation.

Centre for Policy on Aging (CPA): Managing and administering medication in care homes for older people (April 2012) This report focuses on the administering of medication in care homes, it was prepared for the ‘Working together to develop practical solutions: an integrated approach to medication in care homes’ project funded by the Department of Health. The report, which is intended for care home owners, managers and senior staff, draws together information from a variety of sources to describe the extent of the problem, identify common causes and suggest simple and practical ways of reducing the risk of error when administering medication.

NICE guidelines (CG161) Falls in older people: Assessing risk and prevention (June 2013)  provides recommendations for the assessment and prevention of falls in older people. You can use the Multifactorial falls risk assessment within these guidelines to assess falls on admission to care homes.

Welsh National Minimum Standards for care homes for older people   The pharmacy team has the skills and experience to work with their nursing and medical colleagues to support care homes with the development and implementation of standard operating procedures regarding medicines management and administration.

WCPPE Older people  open learning programme will provide you with the key issues affecting medicines management and older people. Detailed information on the ageing process and links to the NSF for Older People and Medicines and older people are provided.

At Ealing Hospital, a pocket guide and handy mnemonic, “MAP”, are helping pharmacists to assess older people’s risk of falling when taking anticholinergic medicines.

Legal and regulatory framework

You should be aware of and familiarise yourself with relevant standards for care homes (including inspection standards), as you can help to address any medication issues and improve the medication safety to help meet the standards.

Care Quality Commission (England) Care Quality Commission (England)

The CQC regulate health and social care services in England, you can view information on care homes, including the different types they regulate on their website. 
They have also published a provider handbook and guidance on meeting regulations for care providers.

Care Inspectorate (Scotland) Care Inspectorate (Scotland)

The Care Inspectorate regulates and inspects care services in Scotland to make sure that they meet the right standards. They also jointly inspect with other regulators to check how well different organisations in local areas work to support adults and children. 
The following national care standards that apply for care homes for adults can be viewed on their website:

Care and Social Services Inspectorate Wales (CCSIW) Care & Social Services Inspectorate Wales (CCSIW)

The CSSIW regulate and inspect to improve adult care, childcare and social services for people in Wales. You can access the regulations and national minimum standards for care homes registered with CSSIW on their website.

General Pharmaceutical Council (GPhC) General Pharmaceutical Council (GPhC)

The GPhC is the independent regulator for pharmacists, pharmacy technicians and pharmacy premises in Great Britain. The standards for conduct, ethics and performance are the core professional standards that all pharmacists and pharmacy technicians must meet.

Mental Capacity Act - Deprivation of Liberty Standards Safeguard Care Act (England, Wales) Mental Capacity Act - Deprivation of Liberty Standards Safeguard Care Act (England, Wales)

The safeguards within this Act cover patients in hospitals, and people in care homes registered under the Care Standards Act 2000, whether placed under public or private arrangements. The safeguards are designed to protect the interests of an extremely vulnerable group of service users and to:

  • ensure people can be given the care they need in the least restrictive regimes
  • prevent arbitrary decisions that deprive vulnerable people of their liberty
  • provide safeguards for vulnerable people
  • provide them with rights of challenge against unlawful detention
  • avoid unnecessary bureaucracy

Further information on this can be viewed on the following links:

The Mental Capacity Implementation Programme (MCIP) has published a booklet titled Making decisions A guide for people who work in health and social care . This booklet tells you about the Mental Capacity Act (MCA), which applies to England and Wales and how it affects the way you work with some of the care home residents. It explains how to help people make decisions and assess their capacity to make the decisions.

CPPE workshop The Mental Capacity Act 2005 and covert administration of medicines aims to develop knowledge and skills to help manage and optimise care for patients who might lack mental capacity to make a specific decision relating to their medicines at a given point in time.

The Mental Welfare Commission for Scotland have published the Good Practice Guide Covert Medication  which applies to situations in which an individual lacks capacity to make a decision regarding medical treatment and refuses treatment.

Information on Advance decision (living will) can be viewed on the NHS Choices website. This includes information on patients refusing treatment.

See also section in this guide on End of Life care and Consent and Confidentiality

Adults with Incapacity (Scotland) Act 2000 Adults with Incapacity (Scotland) Act 2000

The Scottish Government has published a short guide to the Adults with Incapacity (Scotland) Act (2000) on their website.

Prescribing guidance

The role you are interested in or applying to may require you to be an independent pharmacist prescriber. In this section you will find information on becoming a prescriber and tools that will help you to develop and perform in this role.

Becoming a prescriber Becoming a prescriber

We provide comprehensive information on how to become a pharmacist prescriber and what they can do.

Prescribing framework Prescribing framework

The RPS has published an updated single competency framework for all prescribers (July 2016) in collaboration with all the prescribing professions and patients. The Competency Framework outlines a common set of key competencies central to effective performance needed by all prescribers, regardless of their professional background and in addition support for the continued professional development of all prescribers. It also helps support healthcare professionals to be safe, effective prescribers.

Antimicrobial stewardship Antimicrobial stewardship

The RPS has worked with University College London (UCL) to create an online portal, which signposts to resources and information to promote learning about microbiology and antimicrobial stewardship.

You can find out more about the RPS work on antimicrobial stewardship on our website. 

NICE guideline [NG15] Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (August 2015) covers the effective use of antimicrobials (including antibiotics) in children, young people and adults. It aims to change prescribing practice to help slow the emergence of antimicrobial resistance and ensure that antimicrobials remain an effective treatment for infection.

The TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools Antibiotics Toolkit) aims to help influence prescribers’ and patients’ personal attitudes, social norms and perceived barriers to optimal antibiotic prescribing. It includes a range of resources that can each be used to support prescribers’ and patients’ responsible antibiotic use, helping to fulfil CPD and revalidation requirements. Using the resources in the TARGET Antibiotics Toolkit will enable organisations to demonstrate compliance with the Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. The Toolkit also supports recommendations made in the recent NICE guideline: Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use (August 2015) and is linked within the guideline.

Local prescribing guidance and formularies Local prescribing guidance & formularies

You may want to contact your local CCG or Health Board for any available local prescribing guidance or formularies. The care home may also require you to create prescribing guidanxe or formularies for the care home.

When prescribing, it's important to be aware of local NHS medicines optimisation team priorities, so make sure you know what these are.

NICE and SIGN guidance NICE & SIGN guidance

Relevant NICE and SIGN Scotland guidance may be useful to you when prescribing for care home residents.

Networks Networks

Our two dedicated networks, the Pharmacist Prescribing Discussion Group and the Prescribing and Medicines Management Group, may also be useful.
Details
   

Acknowledgments

Working group

The Royal Pharmaceutical Society is grateful to the individuals and organisations who have provided contributions and comment develop this ultimate guide:

  • Francesca Aaen - Care Homes Pharmacist, NHS Lanarkshire
  • Timothy Banner - Consultant Pharmacist
  • Sundus Jawad Bilal - Prescribing and care homes support pharmacist
  • Liz Butterfield - Care Homes Medication Reviews Lead, Brighton and Hove CCG
  • Hilary M Campbell - Prescribing Support Pharmacist
  • Judith Charatan - Lay representative
  • Ann Child - Head Of Pharmaceutical Care And Clinical Standards, Avante Care
  • Anfrances Duggan - Care Home Pharmacist Prescribing Support Pharmacist, Glawsgow CHCP
  • Dawne Garrett - Professional lead older people and dementia care, Royal College of Nursing
  • Alexandra Gibbins - Head of Prescribing and Medicines Management, ABMU Health Board
  • Cherise Howson - Care Homes Pharmacist | Care Homes Support Team | GSTT Adult Community Services
  • Nicole Le Morgan - Lead Proactive Care Homes Pharmacist
  • Barbara E. Jesson - Community Pharmacy Adviser and Lead for Medicine Optimisation Croydon CCG
  • Dr José Moss - Deputy Superintendent Pharmacist, Boots UK Limited
  • Kim Hanh Ho Tran Packham - Senior Policy & Programmes Adviser, Pharmacy Voice
  • William Roberts - National Care Homes Lead | New Care Models Programme – Five Year Forward View
  • Siobhan Smith - Senior Practice Pharmacist
  • Christine White - Care Home Medicines Optimisation Pharmacist (Blackpool Teaching Hospitals)
  • Karen Wragg - CPPE Regional Manager, South Central

Other contributors

Community Pharmacy Practice group

As part of the development the guide was sent to the Community Pharmacy Practice group. We would like to thank all the individuals who provided comments and feedback which was used to help refine the guide.

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