Medicines In Health And Adult Social Care

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Medicines in health andadult social careLearning from risks and sharing good practicefor better outcomes

The Care Quality CommissionOur purposeThe Care Quality Commission is the independent regulator of health and adult socialcare in England. We make sure that health and social care services provide people withsafe, effective, compassionate, high-quality care and we encourage care services toimprove.Our role We register health and adult social care providers. We monitor and inspect services to see whether they are safe, effective, caring,responsive and well-led, and we publish what we find, including quality ratings. We use our legal powers to take action where we identify poor care. We speak independently, publishing regional and national views of the majorquality issues in health and social care, and encouraging improvement byhighlighting good practice.Our valuesExcellence – being a high-performing organisationCaring – treating everyone with dignity and respectIntegrity – doing the right thingTeamwork – learning from each other to be the best we canCare Quality Commission: Medicines in health and adult social care1

ContentsForeword from the Chief Inspector . 3CQC’s role in improving medicines optimisation . 4Summary: the common medicines issues across health and care . 5What all providers can do to improve . 9Introduction . 12Medicines in mental health services . 15Key themes .15Actions for mental health care providers .25Medicines in primary care services . 26Key themes .26Actions for primary care providers .35Medicines in adult social care . 36Key themes .36Actions for adult social care providers .42Medicines in acute hospital services . 43Key themes .43Actions for acute hospital providers .52References . 53Care Quality Commission: Medicines in health and adult social care2

Foreword from the Chief InspectorAcross all health and care services, CQC’s inspections shine a light on quality and enable thepublic to have confidence in the services they use. We celebrate good and outstanding care andshare this so that all services can learn from it and improve; we also highlight where servicesneed to improve where we find poor or unsafe care.This report brings together what we have learned through our regulatory activity about the risksfrom medicines. It raises important issues for everybody involved with medicines in all healthand adult social care settings. We know that there has been a lot of work to ensure safer use ofmedicines across services, but there are still areas that can be improved. We are keen that allhealth and care providers understand the risks, and are able to apply learning from these toenable better outcomes for people using services.Providers often tell us that examples of good practice are a useful tool to help them getthinking about the improvements they can make in their own services. That’s why we sharesome good practice and innovative ways of working in this report, as one aspect of our role is tohelp and encourage continuous improvement.Through our regulatory work in health and care services, we have seen an increased risk ofpoorer experiences and outcomes when people’s care is transferred between services. At thiscritical time, communication can break down around prescribing and supplying medicines,which means people may not always get the right medicines quickly enough, and this can leadto harm.We therefore ask care providers, commissioners and other local stakeholders to reflect on thisreport: be aware of the risks, learn from the examples and think about the actions to usemedicines safely, effectively and for the most optimal outcomes.Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated CareCare Quality Commission: Medicines in health and adult social care3

CQC’s role in improving medicines optimisationWhen CQC inspects health and care services we assess how well they meet people’sneeds. As part of this, we look at how people’s medicines are optimised. Medicinesoptimisation is the safe and effective use of medicines to enable the best possibleoutcomes for people. It also looks at the value that medicines deliver, making surethat they are both clinically and cost effective, and that people get the right choiceof medicines, at the right time, with clinicians engaging them in the process.To do this, CQC has a national Medicines Optimisation Team of pharmacyprofessionals who take ownership for all aspects of medicines in the regulatorycontext. Our team works across the country providing specialist advice on the use ofmedicines in all settings. This includes being on site at inspections, as part of CQC’swider inspection team, and being integral to decisions on enforcement. We work withCQC’s policy teams, ensuring that medicines are high on the agenda and are includedin any changes to the way we inspect.Our team has a strong focus on driving improvement through our extensiveengagement programme with national partners, care providers and externalstakeholders. We have produced a range of resources to help providers make senseof regulations and best practice guidance concerning medicines. These are all on ourwebsite, including information for primary medical services, dental services, andinformation on medicines for adult social care services. We also publish brief guidesfor our inspectors in mental health care settings.Through this report, we want to encourage improvement by sharing what we havefound through inspections – both sector-specific and cross-sector risks aroundmedicines and examples of good practice that all providers can learn from.We also highlight the urgent need for collaborative working to improve howmedicines are managed when people are transferred between different health andcare settings.Pharmacy professionals should play a central role in facilitating this, by promotingthe safe and effective use of medicines across all sectors.Sarah BillingtonHead of Medicines Optimisation at CQCCare Quality Commission: Medicines in health and adult social care4

Summary: the common medicines issuesacross health and careMedicines are used in almost every health and social care setting to improve people’s healthand wellbeing. The use of medicines ranges from GPs prescribing for long-term conditionssuch as diabetes to delivering complex chemotherapy regimes in acute hospital settings.We know that people’s physical and mental health outcomes improve when medicines areused in the best or optimal way and that, when not prescribed or administered correctly, theycan cause harm. Applying the principles of medicines optimisation and good medicinesmanagement is therefore vital across all services.Many of the services that CQC regulates have a role in managing medicines. Throughinspection, we have seen that medicines present a clear risk to people when not usedproperly. Our State of Care report for 2017/18 highlighted that, of the five key questionsthat we ask on inspections, performance for the safe key question is poorest, and thiscommonly affects overall ratings for all types of provider across all sectors. A significant partof our assessment of the safe key question looks at how services manage medicines.Reducing harm from medicines is a key national and international priority, and both theDepartment of Health and Social Care and the World Health Organization (WHO) havecommitted to this. This report aligns with both initiatives and provides additional context forservices in England.As the independent regulator, our role is to help providers of health and care services tounderstand the common areas of risk and where services need to improve how they usemedicines.From our analysis of inspection reports, notifications of incidents and enforcement notices,we have categorised the most common areas of risk with medicines across regulated healthand adult social care services. This did not include providers of online consultations over theinternet or by other remote means, as we have previously reported on these services.These six common areas are summarised as follows.Care Quality Commission: Medicines in health and adult social care5

Figure 1: The six most common areas of risk with medicines across health and carePrescribing,monitoring &reviewingStaffcompetence &workforcecapacityAdministrationCommonareas of riskwithmedicinesSupply,storage &disposalTransfer ofcareReporting &learning fromincidentsPrescribing, monitoring and reviewingGuidance from the General Medical Council is clear that professionals are responsible for theprescriptions they sign and for their decisions and actions when supplying and administeringmedicines, or authorising or instructing others to do so.1 Prescribers and pharmacists supplyingmedicines have a responsibility to keep patients safe and to tell them about any risks in using amedicine. Carrying out timely medicines reviews is also key to ensuring that people’s medicinesremain both safe and effective.Monitoring patients is an essential component of the prescribing process. This covers the initialprescribing to how people’s medicines are monitored over the long term to ensure that theyremain safe and effective. We found examples of risk and unsafe practice across a range ofhealth and social care settings.In general practice, there are risks for patients taking high-risk medicines such as insulin fordiabetes, ACE inhibitors for hypertension, anticoagulants such as warfarin, methotrexate forarthritis and lithium for mental health conditions, as these were not always monitored routinely.Care Quality Commission: Medicines in health and adult social care6

The use of high-risk medicines in acute hospital settings also presents risks for patients. Forexample, anticoagulant medicines to prevent blood clots were not always prescribed or suppliedto patients in a timely way, which increased people’s risk of deep vein thromboses (DVTs);doses of antibiotics were not reviewed frequently and adjusted following the results of bloodtests; and a lack of familiarity and knowledge among ward staff around insulin resulted inmistakes.It is equally important to monitor medicines in mental health settings. We found examples ofpoor monitoring of higher doses of antipsychotic medicines used to treat schizophrenia, andthat staff were not always aware of the correct processes for injecting medicines to reducepeople’s agitation (rapid tranquillisation) and monitoring their physical health afterwards.AdministrationRisks associated with administering medicines were present across all sectors. Our analysishighlighted issues including missed and incorrect doses of medicines (including inadvertentrepeated doses) and poorly managed covert and ‘when required’ administration, which resultsin poorer outcomes. We also saw problems when people self-administered their medicines whenit was not appropriate to do so. Conversely, we found that people were not always supported toself-administer when they were able to. Issues with administration were commonly linked topoor record keeping, which included incorrectly transcribed medicines administration recordsand failure to record administration.Transfer of carePeople who use medicines may follow a pathway of care that can involve both health and socialcare services. The overall effectiveness of such a pathway can often depend on where they live,the range of local care services and how well these services work together to provide joined-upand person-centred care.It is important that medicines are not considered in isolation, but as an integral part of thepathway, and at each step. For example, a person may be admitted from the care of GP andcommunity health services to an acute hospital and then discharged to a care home under thecare of a different GP.Problems with the supply of medicines and how information is transferred put people at increasedrisk of harm when they change from one healthcare setting to another. We highlighted this in ourreport Beyond barriers, which looked at how well services work together to support and care forpeople aged 65 and over with complex and long-term care needs. These risks are ongoing againsta backdrop of pressures on systems and the changing nature of how health care is provided, asseen throu

The Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve. Our role We register health and adult social care providers.

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