When working within a care home, do you understand the CQC inspection process? Hilary Cunningham, information pharmacist at Numark, explains how you can get it right.

As the community-based experts in medicines, pharmacists regularly provide advice on the management of medicines within a care home. Community pharmacists are often asked to conduct advice visits or medicines audits within the care homes that they service, but how many of us understand the inspection process of the care home regulator, the Care Quality Commission (CQC) and, how do we know that the advice we are providing is appropriate?

Management of medicines within care homes falls under Regulation 12 of the Health and Social Care Act 2008 which stipulates that: “Medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe”.

The inspection process

The primary focus of the CQC inspection process is to assess the quality of care experienced by the care home residents.

Each inspection will involve a team of inspectors led by a CQC inspector. The size of the team will be determined by the size of the home and could include team members with specific skills such as dementia specialists, pharmacy inspectors or interpreters. The team may also include an ‘expert by experience’; these are people who have experience of the type of care being inspected either personally or from caring for someone in a similar situation.

During each inspection five key questions are asked:

• Is the service safe? – are people protected from abuse and avoidable harm?
• Is the service effective? – does the people’s care, treatment and support achieve good outcomes, promote a good quality of life and is it evidence based?
• Is the service caring? – does the service involve and treat people with compassion, kindness, dignity and respect? 
• Is the service responsive to people’s needs? – does the service meet people’s needs?
• Is the service well led? – does the leadership, management and governance of the organisation assure a high-quality and person-centred care, support learning and innovation, and promote an open and fair culture?

Pharmacist support

So that community pharmacists can support care homes in meeting the required standards, it is valuable to understand exactly what the inspectors will be looking for.

CQC inspectors will expect to see that the management of medicines within the home complies with NICE Guidance (SC1): Managing Medicines in Care Homes. It is obviously important that pharmacists providing advice visits to care homes are familiar with this guidance.

The key medicines related question asked during an inspection is: “How does the provider ensure the proper and safe use of medicines?” To answer this question the inspection team will investigate eight specific aspects of medicines management within the home.

1. Is the service’s role in relation to medicines clearly defined and described in relevant policies, procedures and training? Is current and relevant professional guidance about the management of medicines followed?

Inspectors will expect the care home to have a comprehensive medicines policy that details all aspect of medicines handling within the care home. Care home staff will be expected to be able to explain the care home policies and procedures. Possible questions could involve:

• procedures for dealing with verbal instructions from prescribers to amend a patient’s medication
• how they would deal with a dispensing or medication administration error
• how would they respond to fridge temperatures outside of the required temperature range
• processes within the care home to ensure that changes to a resident’s medicines are communicated to the pharmacy.

Inspectors would expect to see records of medicines management training that has taken place within the care home. Care home staff should also be able to detail how they would access specific medicines related information. Suitable sources could include healthcare professionals such as a pharmacist, GP, community or psychiatric nurse or reference sources such as BNF, cBNF, MIMS, or the summary of product characteristics (SPC) or patient information leaflet (PIL) of a medicine.

2. How does the service make sure that people receive their medicines as intended, and that this is recorded appropriately?

Ensuring residents receive their medicines as prescribed is an essential part of patient care: as such inspectors will expect to see MAR charts that are accurate and completed at the time of administration.

Specific attention will focus on time- sensitive medicines, such as Parkinson’s disease drugs, to ensure that residents receive these medicines at a time that is clinically appropriate. Records of administration of variable dose medicines should always include details of the dose that was actually given rather than just a simple signature.

All “when required” medicines should be supported with a “when required protocol” in the resident’s care plan. This should document the symptoms that trigger administration of the medicine, the dose to be given, the effect the medicine should have along with the timeline, maximum daily dose and duration of use.

Care home staff should be able to explain the role of homely remedies within the care home including circumstances where it is appropriate for these medicines to be used, professional advice that is sought before using these remedies and the method of recording administration of these remedies.

3. How are medicines ordered, transported, stored, and disposed of safely and securely in ways that meet current and relevant legislation and guidance?

Care homes are required to ensure the continuity of medicine supply for their residents. This requires the home to have an ordering process that meets this requirement.

NICE guidance specifies that care home staff should be given protected time for ordering medicines and that each home should have at least two members of staff that have the training and skills to order medicines. NICE also directs that care homes should retain the responsibility for ordering of medicines and that this should not be delegated to the pharmacy. The inspection team will expect the home to have a suitable ordering process.

Care homes should be encouraged to check prescriptions before dispensing to ensure that all medicines ordered have been prescribed.

The inspectors will also be checking that the home stores the medicines appropriately. Key considerations for the inspection team would include: medicine security; methods for ensuring stability of medicines; safe storage; disposal of medicines; and procedures for storage, recording usage and destruction of Controlled Drugs that comply with Misuse of Drugs regulations.

4. Are there clear procedures for giving medicines covertly, in line with the Mental Capacity Act 2005?

The care home would be expected to demonstrate compliance with all of the legal aspects of covert administration where residents are being administered medicines covertly.

Care home staff would be expected to explain how they would confirm that the proposed method for administering medicines covertly is safe and does not affect the clinical action of the medicine. Care home staff would typically ask their supplying pharmacist for this information.

5. How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

Evidence of regular reviews of resident’s medicines would demonstrate that the home does not routinely use antipsychotic or sedative medicines to control a resident’s behaviour.

The home would also be expected to demonstrate that residents have access to specialist medical services, such as community psychiatric teams, where necessary.

6. How do staff assess the level of support a person needs to take their medicines safely, particularly where there are difficulties in communicating, when medicines are being administered covertly, and when undertaking risk enablement assessments designed to promote self-administration?

The care home should have a procedure for assessing a residents’ ability to self- medicate. This should include the possibility of residents being able to manage some but not all of their medicines. The home should also have a procedure for monitoring patients who are self-medicating to ensure they remain able to do so safely.

The inspection team would expect that the care home staff would be able to explain how this process operates within the home.

Care homes should be able to provide self- medicating residents with facilities to securely store their medicines within their room.

7. How does the service engage with healthcare professionals in relation to reviews of medicines at appropriate intervals?

The care home is required to ensure that residents have access to healthcare services whenever needed. This should include a review of medication at regular intervals. NICE advises that all people over 75 years old should have their medication reviewed at least annually, with those prescribed four or more medicines being reviewed six monthly.

The inspection team would expect care home staff to be able to explain the process for arranging a review of a resident’s medication.

The inspection team would also expect care home staff to be able to explain the home’s process for ensuring residents receive appropriate monitoring checks, such as INR checks, blood lithium or methotrexate levels or kidney function checks for ACE inhibitors, and that appropriate action is taken following these tests.

8. How do staff make sure that accurate, up-to-date information about people’s medicines is available when people move between care settings? How do medicines remain available to people when they do so?

Inspectors would expect care homes to have appropriate procedures for reconciling a resident’s medication when they first arrive within the home. These records should be confirmed with the resident’s GP at the earliest opportunity.

Care homes should also have procedures for providing information regarding resident’s medication to other care providers such as hospitals, new GPs, other healthcare professionals and other care homes. This procedure should also include a process for supplying medication to accompany the resident. Medication should always be supplied in the original labeled container as supplied by the pharmacist.