STANDARD OPERATING PROCEDURE
Title: Medicines Policy SOP
Management of Medicines within Crisis
Home Treatment Teams SOP
Procedure Written By:
Clinical Pharmacist
Chief Pharmacist
Procedure
Resolution & No:
MP3
Procedure
Approved Review
By:
Date:
Medicines Management 22/05/2018
Committee
Document
Replaced:
N/A
Version
2
Next
Pages:
Review
Date:
10
22/05/2020
The Crisis Resolution and Home Treatment (CR/HT) teams provide intensive support at home
for patients experiencing an acute mental health crisis. Medicines are an important aspect of the
care provided to patients who are admitted to CR/HT.
1.1 OBJECTIVE
This Standard Operating Procedure (SOP) provides the procedures that should be followed with
regards to the safe and effective use of medicines when patients are admitted to the care of
CR/HT.
1.2 SCOPE
This procedure is applicable to all Black Country Partnership NHS Foundation Trust (BCPFT)
staff, involved in the management of medicines for patients under the care of CR/HT.
This procedure covers a number of aspects involved in managing a patient’s medication when
they are admitted to CR/HT. The procedure described will aid in the safe and effective
management of medicines within CR/HT teams.
1.3 PROCEDURE
1.3.1 Medicines Reconciliation
Medicines reconciliation should be completed within 24 hours of admission to CR/HT as per
BCPFT policy for reconciliation of medicines on admission to hospital. A request should be
made to the GP for all current treatment (both repeat and acute medication, including doses and
dates of last issue) and allergies. Any relevant laboratory results or physical investigations
should also be requested. A doctor should obtain a medication history from the patient and/or
carer. Any non-prescribed medication taken should be documented e.g. herbal remedies.
Where a patient has been transferred from secondary care i.e. inpatient setting, the inpatient
administration chart or discharge prescription should be used for medicines reconciliation, in
addition to evidence received from the GP. Any documentation to aid in medicines reconciliation
(e.g. GP request of medication, secondary care discharge prescription, community mental
health treatment cards) should be requested by a nurse (may be delegated to non-nursing
staff). Where a nurse is unable to obtain this information a doctor must obtain this information
(may be delegated to non-medical staff).
Documentation regarding medicines reconciliation must be attached or kept with the Medicines
Administration Chart. Any anomalies discovered should be promptly investigated. A doctor
should ensure that medicines and doses are appropriate and any discrepancies are accounted
for and actioned. Any discrepancies, changes, deletions or additions should be documented in
the patient’s notes by a doctor.
Medicines Policy SOP (MP3)
Management of Medicines within Crisis Resolution & Home Treatment
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Information regarding the patient’s adherence to medication should be examined by a doctor
and nurse. Reasons for any non-adherence should be discussed with the patient and/or carer.
Information should be obtained on how the patient takes their medication e.g. medication aids.
A nurse should inform the patient’s GP regarding the treatment plan and plan for access to
further medication supply i.e. who is responsible for prescribing and supplying medication and
information regarding risks and needs assessments. If a patient has a blister pack, information
regarding the dispensing community pharmacy should be obtained (name, address and
telephone number) and they should be notified of the patient’s admission to CR/HT and
treatment plan. This should be completed by a nurse or a doctor where a nurse is unable to
undertake this task.
A member of the pharmacy team will check that medicines reconciliation has been completed
and a pharmacist will clinically screen any prescriptions for patients under the care of CR/HT
when the Medicines Administration Chart and prescription forms are next seen on a pharmacy
visit or submitted to the pharmacy. Any anomalies/queries should be discussed with the
responsible doctor and/or nurse.
1.3.2 Medication Prescribing
All patients under the care of CR/HT must have a Medicines Administration Chart, where there
is involvement with the patient’s medication. The Medicines Administration Chart should provide
a complete picture of the patient’s current treatment and allergy status. This should include
physical and mental health treatment. This must be completed by a prescriber on admission of a
patient to CR/HT. Treatment should be reviewed regularly by the prescriber and the Medicines
Administration Chart updated accordingly.
The Medicines Administration Chart is not a prescription, but a direction to administer. Where
medication is to be supplied to a patient a prescription must be written by a prescriber, on a trust
approved prescription form.
It may be necessary for a prescriber to use a FP10 prescription form. The Medicines
Administration Chart should be annotated by the prescriber or a nurse to state that an FP10
prescription form has been issued, including the duration of supply, and a copy of the
prescription should be filed in the patient’s notes. The management of FP10 prescription forms
should comply with the BCPFT FP10 Policy.
On discharge, a detailed account of the patient’s medication and treatment plan must be
communicated to the GP and community mental health team by the responsible prescriber.
Where patients require any sort of medication aid, the treatment plan should also be
communicated to the necessary healthcare professional(s) e.g. community pharmacist, by the
doctor or nurse.
1.3.3 Accessing Medication
Patient’s Own Drugs (PODs)
Patients may be receiving regular prescriptions/medications from their GP and community
pharmacy. On admission to CR/HT, a nurse should determine the supply of medication a patient
has in their possession. Where possible, the patient should continue to self-administer their own
medication.
Temporary removal of PODs may need to be negotiated with the patient in certain
circumstances e.g. risk of overdose. Where possible medication should be given to a family
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Management of Medicines within Crisis Resolution & Home Treatment
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member or carer for safe-keeping, but can be stored at the CR/HT base for safe keeping if
needed. Where medication is removed and stored at the CR/HT base, consent should be
obtained and recorded by a nurse (Appendix 1). If medication is removed without consent,
reasons for this should be documented. This should be discussed with the multidisciplinary
team and the family/carer. Where the patient’s own medication is stored at the CR/HT base,
CR/HT may need to facilitate taking the medication to the patient for administration/selfadministration of their doses. PODs should not be re-packed/split. A nurse should first assess
the suitability of the PODs (see BCPFT Medicines Policies.) When the patient is able to selfadminister safely or is discharged from CR/HT their own medication should be returned to them
where appropriate.
Pharmacy
Medication supplied to a patient by CR/HT should be obtained from a pharmacy service.
Medication should be obtained via the BCPFT Pharmacy Team and allocated pharmacy service
provider. Where the pharmacy service provider is closed or this service is not available a FP10
prescription form may be used and taken to a community pharmacy for dispensing. It is the
prescriber’s responsibility to ensure that a prescription is available for any medication to be
supplied by CR/HT to a patient. It is the responsibility of a nurse to obtain a supply of medication
from a pharmacy and ensure this is provided to the patient.
In some cases, medication may be dispensed by pharmacy as short supply periods e.g. daily
supply. A risk and needs assessment should govern this method of supply. This should not
represent routine practice as it may disempower the patient with regards to taking medication.
Prescribing should accurately reflect the need for this type of dispensing. This must be reviewed
regularly and the patient given responsibility of managing their own medication at the earliest
time, to prepare them for discharge.
CRHT Stock
Where the allocated pharmacy service provider and a community pharmacy is unavailable i.e.
out of hours, then a nurse can take the required medication from stock and administer this to a
patient against a valid direction to administer. Where medication is to be supplied to a patient it
must be dispensed according to legal standards (see section 1.3.7).
GP
Where a patient’s GP is in agreement, it may be appropriate to liaise with the patient’s GP with
regards to treatment and obtaining medication. In this way CR/HT may facilitate support to the
patient via their GP.
1.3.4 Supply, Administration and Recording
All patients should have an individualised care plan to reflect their medication needs. There are
a number of methods by which CR/HT may be supporting a patient with medication. This will be
governed by involvement of the patient/carer and continuing assessments by CR/HT at each
point of contact. A patient may not fall into one method of support with medication, but may be
receiving a combination depending on their care plan. A nurse must clearly endorse the
Medicines Administration Chart to reflect this. This should clearly identify how the patient is
receiving and taking medication. The methods by which a patient may be receiving and taking
medication are briefly outlined;
1) Self-Administration (Obtaining medication from the GP)
CR/HT may only be providing a supportive role and the patient may continue to obtain and selfadminister their own medication from their GP and community pharmacy. The Medicines
Medicines Policy SOP (MP3)
Management of Medicines within Crisis Resolution & Home Treatment
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Administration Chart should be annotated with ‘Self-Administration- From GP’ or something
similar to indicate this.
2) Self-Administration (Obtaining medication from CR/HT)
CR/HT may need to supply medication to a patient until they can be discharged back to the care
of their GP. CR/HT are likely to initiate/make changes to mental health treatment only, so the
patient should be advised to continue obtaining their physical health treatment from their GP.
The GP must be notified of the care plan with regards to the supply of medication. The patient
should be informed of this so they can raise any concerns with their GP and community
pharmacy for medication that may be prescribed for them, but has been stopped or changed by
CR/HT. In this role CR/HT are supplying medication to the patient for self-administration (either
delivered to the patient or the patient collects from the CR/HT base). The Medicines
Administration Chart must be endorsed to reflect the supply of medication i.e. date of supply
and quantity supplied.
3) Observation
CR/HT may be observing self-administration of some or all medication doses to aid adherence
to medication. The patient may be in control of obtaining or keeping their own medication (either
supplied from the GP or CR/HT), but doses are to be observed by a nurse. If medication is to be
stored at the CR/HT base, a nurse will need to deliver the medication to a patient to enable
them to self-administer doses under observation and the medication then be returned to the
CRHT base for safe storage. The Medicines Administration Chart should be endorsed to reflect
any doses that have been observed by CR/HT.
A nurse may delegate delivery and observation of self-administration to a healthcare support
worker, where they have been trained and are deemed competent to undertake this task. On
return to the CRHT base, observation must be confirmed with the nurse on duty, including any
problems or concerns, and documented in the patient’s notes. In this role the trained healthcare
support worker does not handle the individual medication, but delivers medication for selfadministration.
4) Administration of Medication
Where medication is to be stored at the CR/HT base and the patient requires greater support
than observation of self-administration, a nurse will need to visit the patient with medication to
enable them to receive their medication doses and the medication then be returned to the
CR/HT base for safe storage. In this role the nurse may need to handle the individual
medication to facilitate immediate administration of doses. Only nurses should administer
medication i.e. where medicines are individually handed to a patient for immediate observed
consumption. This should be reviewed regularly to ensure that the patient is empowered to take
responsibility for their medication at the earliest possible time. The Medicines Administration
Chart should be endorsed to reflect that medicines have been administered i.e. signed by a
nurse.
If a patient is transferred to an inpatient service any medication supplied to that patient i.e. their
own or supplied via CR/HT, should be transferred with them to ensure continuity of care.
1.3.5 Issuing Medication
Medication should only be issued to a patient where a valid prescription is available for that
patient. The medication to be supplied should be checked against the Medicines Administration
Chart and prescription by a nurse. If there are any doubts about issuing medication e.g. clarity
of a prescription or there are discrepancies between the Medicines Administration Chart,
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Management of Medicines within Crisis Resolution & Home Treatment
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prescription form and medication issued by pharmacy, this should be discussed with a doctor or
pharmacist.
When issuing medication, special care must be taken to confirm that medication is issued to the
correct patient (or carer, where this has been agreed in the care plan). The identity of the patient
should be confirmed by asking for patient specific information and checking against the details
held by CR/HT e.g. name, date of birth, address. The patient should also be asked if they have
any allergies prior to issuing any medication to ensure they are not allergic to any of the
prescribed medication (consult a doctor if an allergy is reported).
When issuing medication, ensure that the patient and/or carer fully understand how to take the
medication. CR/HT may need to provide further information about medication. Advice can be
obtained from a doctor or pharmacist.
Where CR/HT are monitoring adherence in the form of observation or administration, the patient
should always be encouraged to read and follow the instructions on the medication, ensuring
they fully understand the directions, and self-administer the medication. This will empower the
patient to take their medication independently and better prepare them for discharge.
1.3.6 Stock Checking
CR/HT have access to a limited supply of stock medication. The medication will be listed on a
stock list and should be reviewed regularly. This should only be accessed when a supply of
medication cannot be obtained from a pharmacy service i.e. out of hours and where treatment
cannot be delayed until medication can be obtained from a pharmacy service.
A record of each medicine held as stock must be made in the stock record book/file. A qualified
nurse must enter all stock received and all stock administered or supplied to a patient. Any
stock returned should be recorded back into the stock record book/file. Any destruction or return
of medication to pharmacy must be checked by two nurses or a nurse and a
pharmacist/pharmacy technician. A running balance must be kept. The stock balance should be
checked weekly by two nurses to ensure an accurate balance is maintained and the stock held
corresponds with the records made. Any discrepancies must be immediately reported to the
team lead for investigation and a DATIX entry completed.
1.3.7 Dispensing
All supply and dispensing of medicine should meet legal requirements and standards. All
dispensing should routinely be undertaken by a pharmacy service. There may be occasions
where this is not possible e.g. out of hours, where a pharmacy service is unavailable.
Where a supply of medication is deemed clinically urgent and cannot wait until a supply can be
obtained from a pharmacy service or a nurse cannot facilitate administration of medication
doses, it may be necessary for the CR/HT team to dispense medication for a patient. Only
trained nurses can undertake the practice of dispensing. The procedure for emergency
dispensing should be followed (Appendix 2). The Medicines Administration Chart is not a
prescription, but a direction to administer. Where medication is to be supplied to a patient a valid
prescription, which has been written by a prescriber on a trust approved prescription form, must
be available.
Medicines Policy SOP (MP3)
Management of Medicines within Crisis Resolution & Home Treatment
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1.3.8 Storage, Transportation and Disposal of Medication
1.3.8.1 Storage
Storage of medicinal products must comply with the BCPFT Medicines Policy. All medicinal
products must be stored in accordance with the patient information leaflet or summary of
product characteristics document found in dispensed UK-licensed medication.
1.3.8.2 Transport
Transportation and delivery of medication must comply with the BCPFT Medicines Policy. If
non-nursing staff are delegated to deliver medication a nurse must personally handover the
medication to the member of staff with any instructions required and ensure that the non-nursing
staff member is able to complete this task in compliance with the BCPFT Medicines Policies.
On return to CR/HT base, delivery must be confirmed with the nurse on duty, including
any problems or concerns, and documented in the patient’s notes.
1.3.8.3 Disposal
Disposal of Medication must comply with the BCPFT Medicines Policy. Any PODs no longer
required should be returned to a community pharmacy for destruction by the patient or their
carer. In some circumstances, where deemed essential for a patient’s safety and with their
consent (see Appendix 1), medicines may be removed and taken to a community pharmacy for
destruction by a nurse. As a last resort, where PODs cannot be returned to a community
pharmacy, medicines for destruction may be bought back to the CR/HT base and disposed of in
a pharmaceutical waste bin for destruction.
1.4 Responsibilities
The CR/HT team leads and CR/HT consultant leads have overall responsibility to ensure that all
members of their respective CR/HT teams follow the processes set out in this procedure. Each
team should have a nominated medicines management nurse and doctor who can lead on
medicines management within their CR/HT team (this may be a team lead or consultant lead).
1.5 COMPLIANCE TO THIS SOP
Compliance with the policy will be monitored by the CR/HT team lead. The team lead will audit
the compliance annually.
1.6 REVIEW OF THIS STANDARD OPERATING PROCEDURE
This SOP will be reviewed every two years from the date of approval or sooner if warranted due
to any incidents occurring before next review date.
2.0 REFERENCES / FURTHER INFORMATION




National Clinical Health and Clinical Excellence (2007). Technical Patient Safety
Solutions for Medicines Reconciliation on Admission of Adults to Hospital (Available
from:http://www.nice.org.uk/nicemedia/pdf/PSG001Guidance.pdf)
Royal College of Psychiatrists (2013). Home Treatment Accreditation Scheme (Available
from: https://www.rcpsych.ac.uk/pdf/HTAS%20Standards%20First%20Edition-2013.pdf)
College of Mental Health Pharmacy (2009). Getting the Medicines Right 2: Medicines
Management in mental Health Crisis Resolution and Home Treatment Teams (Available
from:http://www.nmhdu.org.uk/silo/files/getting-the-medicines-right-2.pdf)
Nursing & Midwifery Council (2007). Standards for Medicines Management (Available
from:http://www.nmc-uk.org/Nurses-and-midwives/Regulation-in-practice/Medicinesmanagement-and-prescribing/)
Medicines Policy SOP (MP3)
Management of Medicines within Crisis Resolution & Home Treatment
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Appendix 1
Patient’s Own Drugs Consent Form
NAME:
DATE OF BIRTH:
ADDRESS:
NHS NUMBER:
Item Medicine, Form, Strength
Dose & Frequency
Quantity
Comments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I give consent to the Crisis Resolution and Home Treatment Team to take the medicines listed
for safe-keeping and they may dispose of any medication that is no longer appropriate for use.
Patient Name
………………………………….
Patient Signature
………………………………….
Date
………………..
The patient is unable to give consent (details written in the patient’s notes)
Nurse Name
………………………………….
Nurse Signature
………………………………….
Date
………………..
Medicines Policy SOP (MP3)
Management of Medicines within Crisis Resolution & Home Treatment
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Appendix 1
Returned
Items numbered …………………………………………………….. have been returned to the patient.
The patient must check with their doctor before using them again. The risks have been explained.
Patient Name
………………………………….
Patient Signature
………………………………….
Nurse Name
………………………………….
Nurse Signature
………………………………….
Date
………………..
Date ………………..
Disposal
Items numbered …………………………………………………….. have been returned to
a
community pharmacy for disposal/returned to a hospital pharmacy for disposal/disposed of in a
pharmaceutical waste bin
(Delete as appropriate)
Nurse Name
………………………………….
Nurse Signature
………………………………….
Date ………………..
Medicines Policy SOP (MP3)
Management of Medicines within Crisis Resolution & Home Treatment
Page 8 of 10
Appendix 2
Procedure for Emergency Dispensing by Qualified Nurses Working in Crisis Resolution and
Home Treatment Teams
Objective
This procedure is designed to aid qualified nursing staff working within Crisis resolution and
Home Treatment teams to dispense medication.
‘The definition of dispensing is “To label from stock and supply a clinically appropriate
medicine to a patient, client or carer, usually against a written prescription, for selfadministration or administration by another professional, and to advise on safe and effective
use’’. Dispensing includes such activities as checking the validity of the prescription, the
appropriateness of the medicine for an individual patient, assembly of the product, labelling
in accordance with legal requirements and providing information leaflets for the patient’.
(Nursing & Midwifery Council, 2010: Standards for Medicines Management)
This procedure should only be used where medication cannot be obtained from a pharmacy
service and a qualified nurse is unable to facilitate a visit to the patient to administer doses
at the prescribed frequency. Nurse dispensing should not be commonplace and should only
occur in urgent situations when medication cannot be obtained from a pharmacy and cannot
wait until a pharmacy is available to dispense medication.
Scope
This procedure should only be undertaken by a qualified nurse working within CRHT that
has received training in the practice of dispensing.
Procedure
Two qualified nurses should undertake the activity of dispensing (one dispenser and one
checker). A maximum of 24 hours of medication can be dispensed. This should allow
sufficient time for medication to be obtained from a pharmacy service.
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Management of Medicines within Crisis Resolution & Home Treatment
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Appendix 2
Step 1: Professional Check
Step 2: Dispensing
Step 3: Checking
1.
1.
2.
1.
2.
Assemble all the documents needed
for dispensing
a. Medicines
Administration
Chart
b. Valid Prescription
Check the appropriateness of the
prescription
a. Check that it correspond to
the Medicines Administration
Chart
b. Check that the prescription is
legal and valid
c. Check that the prescription is
clinically
safe
and
appropriate for the patient
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Ensure the dispensing workspace is clear
Select the correct medicine, strength and form as stated on
the prescription
Check the expiry date of the medicine
Check the quantity corresponds with the stock register
Select the pre-printed label for the medicine to be dispensed
Complete the required fields on the label according to the
prescription
a. Name of patient
b. Dose
c. Quantity of medicine dispensed
d. Date of dispensing
Select a medicine carton and stick the label to the carton
Select the quantity of medicine needed from the stock
medicine and dispense into the labelled medicine container
Double check that the correct medicine, strength and form
has been selected in accordance with the prescription
Double check the expiry date of the medicine
Double check the label details have been completed and the
quantity dispensed are all in accordance with the prescription
Ensure that the stock register has been updated and the
running balance is correct
Supply the appropriate Patient Information Leaflet (PIL)
Sign the dispensed box (D) on the label once the dispensing
checks have been completed
Leave the components used for dispensing on the dispensing
surface for a second nurse to check
2.
3.
4.
Medicines Policy SOP (MP3)
Management of Medicines within Crisis Resolution & Home Treatment
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Dispensing must be checked by a second nurse
a. Check
the
appropriateness
of
the
prescription
b. Check that the correct medicine, strength
and form has been dispensed
c. Check the expiry date of stock medication
used
d. Check that the correct label has been
attached to the container
i. Patient details
ii. Dose
iii. Quantity
iv. Date of Dispensing
v. Dispensed by box signed
e. Check that a PIL has been supplied
f. Check that the entry in the stock register is
correct and that the running balance is
correct.
Once the second check has been completed, sign the
checked box (C)
All components for dispensing should be returned to
their original storage area
Store the dispensed medication safely as for any other
medicine in a locked cabinet.