Covert administration of medication in a care home

The covert administration of medication is monitored closely by the Care Quality Commission during inspections and monitoring calls. If a home is administering medication covertly, the home's policy for administering medication should make provision for the administration of covert medications.

Suppose a person has mental capacity to make decisions about taking medication. In that case, they have a right to refuse medication, even if that decision is considered unwise by Doctors, staff at the home or family members.

Covert medication administration should only be considered when a person is assessed as not having the capacity to understand the consequences of refusing the medication. The determination of capacity is defined by the Mental Capacity Act 2005. The medicine is deemed essential to the person's health and well-being by a medical practitioner.

Every effort should be made to assist the person to take the medication before cover administration is considered. This may include changing the formulation or presentation of the medication to improve acceptability.  If covert medication administration is implemented, it should be the least restrictive option available to the person. Other alternatives should have been considered first.

Once the lack of mental capacity has been established, all decisions must be in the person's best interests. Consideration should be given to the impact on the person's health and well-being. A multi-disciplinary team should decide on the use of covert administration of medicines.

The best-interest meeting should occur in person or remotely, but clear records of that meeting should be taken. The discussion should include care staff, health professionals prescribing the medicines and family or advocate. Under no circumstances should the decision be handled by one person alone.

The decision to administer covert medication should be medicine specific. The decision should be reassessed each time new drugs are added or the dose is changed to an existing medicine. Aside from changes in prescription, covert medication administration and mental capacity should be kept under regular review.

Care Home staff should be aware some medicines can become ineffective when mixed with certain foods. Crushing tables or opening capsules may make its use "off-licence". Therefore if medications are to be administered this way, advice should be sought from the prescriber and pharmacist.

Medication Administration Records must clearly record the route of administration, if the item is to be administered covertly, there should be clear preparation instructions, what dilution method is approved and frequency.

The care plan of someone receiving covert medication should include the following:

Actions taken to give medicines in a normal way, and how they will be administered covertly in the future. There should be specialist input to show the suitability of the method chosen, for example, crushed in food. Suppose there is a swallowing difficulty or if the medication is unpalatable?

The care plan should specify the reason for the drug and the possible consequences of not taking the medication. Advice should be available to staff as to what to do if the person refuses the food or drinks the drug has been dispensed in, and how to monitor effectiveness.

In the event of difficulties in administration, there should be contact information available for the prescriber and clearly defined escalation routes for concerns.

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