The importance of effective medicines recording as part of a home care service

Featured article - 15 October 2018
By Keith Lowe; Consultant, NICE Quality Standards committee member and former regulator

Head-shot of the author, Keith Lowe; Consultant, NICE Quality Standards committee member and former regulator

Within my work with home care providers, I have often been asked to identify those activities which present the greatest risk to people using services. Although this does depend on the service provided by individual providers, the safe recording of medicines is probably the one activity that many services fail to consistently get right.

I would always recommend that providers who have responsibilities for medicines support, to have procedures in placed based on current legislation, guidance and best practice which includes:

  • assessing a person's medicines support needs
  • ensuring that records are accurate and up to date
  • managing concerns about medicines, including medicines-related safeguarding incidents.

In addition, there should also be a focus on the responsibilities for ordering and supplying medicines, the storage and disposing of medicines and medicines-related staff training including the ongoing assessment of competency.

My experiences were useful to help the National Institute for Health and Care Excellence (NICE) produce the quality standards for providers which cover a range of aspects of managing medicines including safeguarding and medicines-related problems.

Communication is the key

I have often found that many problems can occur where the responsibility for medicines is shared between more than one care worker, provider and the person’s immediate family. These difficulties are easily remedied through good communication between the different staff and carers in these settings and through the timely sharing of information; to help reduce medicines errors and safety incidents.

Robust Records management

I have supported providers to develop robust records management systems to ensure medicines administration is effective and minimises the risk of errors. For example, I would advise that changes to records are only made and checked by people who are trained and assessed as competent to do so. I have observed that high-quality governance through regular audits by managers can demonstrate that medication administration is timely and records are accurate and up to date.

You are not alone

Using the NICE quality standards, SCIE have produced a useful quick guide for home care managers who provide medicines support.

The guide provides advice on the importance of record keeping and checking and ordering medicines and what to expect from health care professionals.

Keith Lowe is an independent consultant; a standing member of the NICE Quality Standards Advisory Committee Three; and former social care regulator.

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