Covert Administration of Medicines in Care Homes

COVERT ADMINISTRATION OF MEDICINES IN CARE HOMES POLICY CONTENTS PAGE 1. Introduction 3 2. Scope of Policy 3 3. Definition 3 4. Purpose 3 5. Exceptions to protocol 4 6. Education and training 4 7. Monitoring and review 4 8. Implementation and dissemination 4 9. References 5 10. Covert Medication Administration Policy for Care Home 6 Appendices Appendix 1: Flowchart for use of covert medication 12 Appendix 2: Covert Administration Medication Record Form 13 Appendix 3: Covert Administration Guidance from Community Pharmacist 15 Appendix 4: Administration of Covert Medication Review Form 16 Covert administration of medicines policy Page 2 Document prepared by: NHS Cambridgeshire and Peterborough CCG Medicines Optimisation Next Review: January 2022 1. INTRODUCTION 1.1. Covert medication may be appropriate for those individuals who have been assessed as lacking mental capacity, in exceptional circumstances, to prevent a person from missing out on essential treatment. 2. SCOPE OF POLICY 2.1. This policy provides guidance to care home staff regarding the covert administration of medications and explains when this can be done, within the law. 3. DEFINITION OF COVERT ADMINISTRATION OF MEDICATION 3.1. Covert administration of medication occurs when medications are administered in a disguise format without the knowledge or consent of the person receiving them, for example in food or in a drink. Covert administration of medication can only be necessary and justified in exceptional circumstances, when certain legal requirements have been satisfied. Medicines should never be administered covertly to patients who have capacity to make their own decisions. 3.2. For patients with swallowing difficulty, medication can sometimes be administered with soft food or in a drink and this would not be considered as covert if the patient is fully aware, and has consented, to having their medication administered in this way. Patients must be advised that their medication has been mixed with food/liquid every time it is administered, and this should be clearly documented. Where medication is mixed with food/liquid, care staff must ensure that the entire dose is administered to the patient and that it is not left unattended, ensuring that other residents do not have access to it. Crushing medications and mixing them with food/liquids often renders each medication unlicensed. The prescriber must therefore consent and authorise such practice in writing prior to administering medication in this way. Advice on mixing medication with food/liquids must always be sought from a pharmacist. (Contact CCG Prescribing Partnership: [email protected], your local community pharmacist or practice (GP surgery) pharmacist for written advice on crushing medications and/or mixing with food/liquids). 4. PURPOSE 4.1. This policy is intended for use by registered practitioners or carers working within Cambridgeshire and Peterborough CCG, who may be planning the use of covert medication or who may be administering medications covertly as part of a treatment plan, within the care home setting. It is important that the guidance within this policy is followed every time covert medication is used or whenever it is being considered. Covert administration of medicines policy Page 3 Document prepared by: NHS Cambridgeshire and Peterborough CCG Medicines Optimisation Next Review: January 2022 4.2. All care home providers must have procedures for arranging for covert administration of medicines. This policy will provide guidance around the decision-making process and the documentation required to administer medicines covertly. 5. EXCEPTIONS TO GUIDANCE 5.1. Extreme Situations: When an emergency arises in a clinical setting, and it is not possible to determine a patient’s wishes, they can be treated without their consent provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition. The treatment provided must be the least restrictive option available. Any medical intervention must be considered in the patient’s best interests and should be clearly recorded noting, who took the decision, why the decision was taken, and what treatment was given. 6. EDUCATION AND TRAINING 6.1. All staff involved in the administration of medicines should be aware of this guidance and appropriately trained. 7. MONITORING AND REVIEW 7.1. The policy will be reviewed every two years by the Cambridgeshire and Peterborough CCG Medicines Optimisation Team (MOT), or earlier in the event of changes to legislation or good practice. 7.2. The MOT will include assurance regarding the use of covert medications during the care home reviews that it is involved with and support care homes, where required, using the guidance within this policy. If covert medication is being administered without the appropriate measures taken, or supportive documentation, then this will be discussed with safeguarding colleagues. 8. IMPLEMENTATION AND DISSEMINATION 8.1. Prescribers and care providers need to be aware of the requirements when carers/nurses are requested to administer medication covertly. Both the prescriber and responsible individual within the care setting should ensure that mental capacity has been assessed, medication reviewed, best interest decision process followed, and that all documentation has been completed. Documentation must be maintained, kept up to date and reviewed regularly. The Mental capacity assessment (MCA) must specify that the person assessed lacks capacity to understand the consequences of refusing to take their medication. The Best Interest agreement must specify the medications being considered for covert administration. Documentation supporting covert administration is specific to the organisation, carrying out the assessment, which is responsible for the individual at that time. If a resident has a covert administration plan in place and they are admitted to hospital, this should be reassessed by the Covert administration of medicines policy Page 4 Document prepared by: NHS Cambridgeshire and Peterborough CCG Medicines Optimisation Next Review: January 2022 admitting hospital. Likewise, if a plan is in place in hospital, it should be reassessed once the resident is in the care home. This is to ensure that all contributing factors (e.g. delirium, unfamiliar environment etc) are considered, and covert administration does not continue unnecessarily. 8.2 As part of any decision to administer medication covertly there should be a discussion between the prescriber and those administering the medication as to whether there is a need to also consider Deprivation of Liberty (DoLS) / Liberty Protection Safeguards (LPS). In situations where the person resides in Care/Nursing Home the responsibility for making the application sits with the Care Provider (as the Managing Authority). Covert Medication is a serious interference with a person’s autonomy and right to self- determination. Safeguards by way of review are essential. Patients with existing DoLS/LPS must have covert medications declared and listed, and any change of medication or treatment should trigger a review. 9. REFERENCES NHS Shropshire CCG & NHS Telford and Wrekin CCG, Covert administration of medicines policy, February 2014. www.telfordccg.nhs.uk/download.cfm?doc=docm93jijm4n3922.pdf NHS PrescQipp, Care Homes – covert Administration, September 2015. https://www.prescqipp.info/resources/viewcategory/390-care-homes-covert-administration Covert administration of medicines policy Page 5 Document prepared by: NHS Cambridgeshire and Peterborough CCG Medicines Optimisation Next Review: January 2022 10. Covert Medication Administration Policy for Care Homes General principles of covert administration Human rights law is the first principle that determines the decision to proceed. The right to respect for private life means that individuals capable of making the decision have the right to accept or refuse medical treatment, even where a refusal might lead to a detrimental outcome. Covert medication cannot be given to someone who is capable of deciding about medical treatment. The first step in the process is ascertaining the capacity of a person to make a decision about their medical treatment. Where covert administration is being considered as the most appropriate option, the following principles should be seen as good practice: • Last resort - covert administration is the least restrictive when all other options have been tried. • Medication specific - the need must be identified for each medication prescribed. • Time limited - it should be used for as short a time as possible. • Regularly reviewed - the continued need for covert administration must be regularly reviewed within specified time scales, as should the person’s capacity to consent. • Transparent - the decision-making process must be easy to follow and clearly documented. • Inclusive - the decision-making process must involve discussion and consultation with appropriate advocates for the patient. It must not be a decision taken alone. • Best interest - all decisions must be in the person’s best interest with due consideration to the holistic impact on the person’s health and well-being. Suggested care pathway with supporting flowchart (Appendix 1) Step 1: Assessing mental capacity (MCA assessments) Before covert administration is considered as an option, decisions and actions carried out under the Mental Capacity Act 2005 should be tested against the five key principles set out below. It is important to remember

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