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Care, Learning and Wellbeing

Consultation Draft - Policy on Management and Administration of

Medication

Consultation 22.07.13 – 16.08.13

Contents1. Purpose..........................................................................................................................................1

Forward any comments to:

Ms Z McIntyre

[email protected]

(01292) 612916

mailto:[email protected]

2. Aims and Objectives.......................................................................................................................1

3. Policy Scope...................................................................................................................................1

4. Definition of Medication................................................................................................................2

5. Legislative and Policy Framework..................................................................................................2

Legislation......................................................................................................................................2

Care Inspectorate...........................................................................................................................3

Scottish Social Services Council Standards.....................................................................................3

Scottish Government National Care Standards..............................................................................3

Scottish Government The Administration of Medicines in Schools................................................3

6. Core Principles of Safe/Appropriate Handling of Prescribed Medications.....................................4

7. The Five ‘Rights’ of Medication Administration.............................................................................4

8. Administering Medicines to Individuals – the Legal Position and Attaining Consent.....................4

9. Equality..........................................................................................................................................5

10. Roles and Responsibilities..............................................................................................................6

11. Assessment Process.......................................................................................................................7

12. Management and Administration of Medication - General Standards..........................................7

13. Reporting Errors.............................................................................................................................8

14. Data protection/ Handling Confidential Information.....................................................................8

15. Indemnity Statement.....................................................................................................................9

16. Compliance....................................................................................................................................9

17. Complaints.....................................................................................................................................9

18. Monitoring and Evaluation..........................................................................................................10

Appendix 1 Service Specific Procedures Checklist...............................................................................11

Appendix 2 South Ayrshire Council Risk Assessment...........................................................................13

Appendix 3 Example of South Ayrshire Council Internal Incident Report Form...................................15

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1. Purpose1.1. South Ayrshire Council and associated partner agencies, which include the NHS, private providers

and third sector organisations - referred to from here as Partners - have a requirement under the National Care Standards to have a written policy in relation to assistance with management and administration of medication.

1.2. National guidelines and Health and Social Care legislation place a duty on the Council and Partners to comply with recognised best practice to promote the safety and wellbeing of individuals and employees.

1.3. This policy and its associated service procedures address these requirements and obligations.

Q1. Do you agree with the Purpose as set out in the policy?

2. Aims and Objectives2.1. The aims of this policy and associated service specific guidelines are to:

support individuals who need help with the management and administration of their medication;

provide support and guidelines for employees who support individuals with management and administration of medication.

2.2. The objectives of the policy are to:

encourage individuals to stay independent and carry out as many self-care skills in relation to the management and administration of medication as possible

reduce the risk of errors in the management and administration of prescribed medication;

ensure clear, concise and robust systems are in place that promote effective communication;

standardise documentation with service specific amendments agreed and adopted where necessary;

ensure employees receive training, instruction and information relating to the administration of medication;

ensure the assistance required by an individual is determined by an appropriate assessment, that this is outlined in a Care and Support Plan and re-assessment follows any change in the individual’s situation.

Q2. Do you agree with the Aims and Objectives as set out in the policy?

3. Policy Scope3.1. This Policy applies to all employees who provide assistance in the management and

administration of medication to the individuals of South Ayrshire.

3.2. This includes employees in: Early Years Establishments and Schools Care Homes Home Care Respite Services Day Care Services

Q3. Do you agree with the Policy Scope as set out in the policy?

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4. Definition of Medication4.1. For the purposes of this policy, medication will be defined as prescribed substances which can be

taken orally, inhaled or absorbed through the skin.

4.2. When used correctly, medication can fight infection, relieve pain and other symptoms, as well as control disease and disorders.

4.3. South Ayrshire Council recognise that for some people prescribed medication is not their preferred or primary health care system of choice, and may therefore access other health care systems, such as homeopathic medicines.

4.4. The Council values diversity and respects the individual’s right to such choices, however Council employees or staff providing service under contract, cannot participate in any activity other than for those medicines / treatments prescribed or recommeded by a legally registered medical practitioner.

4.5. This includes the purchasing, collection, administering and disposal of medication/remedies/treatments outside the scope of this policy.

Q4 Do you agree with the Definition of Medication as set out in the policy?

5. Legislative and Policy Framework

Legislation5.1. A legislative duty of care is placed on the Council and Partners which relates to the care, safety

and wellbeing of individuals receiving services and safety of employees who deliver services.

5.2. The following is a list of legislation that has a direct impact upon the handling of medication. This list is not exhaustive and all employees should be able to access documentation pertinent to the administration of medication:

The Social Work (Scotland) Act 1968 (as amended by the Regulation of Care Act 2001)

The Medicines Act 1968

The Misuse of Drugs (Safe Custody) Act1973

Health and Safety at Work Act 1974

The National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009

Reporting of Injuries, Diseases & Dangerous Occurrence Regulations (1995)

The Data Protection Act 1998

The Human Rights Act 1998

Managing Health & Safety at Work Act (1999)

Adults with Incapacity (Scotland) Act 2000

The Regulation of Care (Scotland) Act 2001

Mental Health (Care and Treatment) (Scotland) Act 2003

Adult Support and Protection (Scotland) Act 2007


Education (Scotland) Act 1980

Additional Support for Learning (Scotland) Act 2009

Care Inspectorate5.3. The Care Inspectorate is the independent regulator of social care social work and child protection

services in Scotland for the benefit of the people who use them.

5.4. The Care Inspectorate publishes a range best practice guidelines relating to the service areas outlined above.

5.5. All service specific guidelines must identify and comply with these best practice guidelines.

Scottish Social Services Council Standards5.6. The Scottish Social Services Council (SSSC) Standards for Employers and Employees guide how

employers and their social care staff practice to promote best standards in care settings.

5.7. Social Care Services must produce policies and procedures which are consistent with the SSSC standards.

5.8. All service specific guidelines must comply with these standards.

Scottish Government National Care Standards5.9. The Scottish Government National Care Standards give guidelines which relate to the rights

individuals have when receiving care services irrespective of where these are delivered.

5.10. There are six main principles behind the standards. South Ayrshire Council is committed to adhering to these principles which are defined as:

1. Dignity – to treat individuals with respect at all times.

2. Privacy – to respect personal privacy property of the individual.

3. Choice – to give individuals the opportunity to choose, knowing what choices they have.

4. Safety – to help the individual feel safe without being over protected.

5. Realising Potential – to help the individual to make the most out of life.

6. Equality and Diversity – to help the individual live in an environment free from bullying, harassment and discrimination and in a way they choose.

Scottish Government: The Administration of Medicines in Schools5.11. These guidelines were written in 2001 to help National Health Service Boards and Education

Authorities to draw up policies on managing health care in early years establishments and schools. Its advice applies to early years establishments, primary, secondary and special educational establishments.

5.12. All Service Specific Guidelines must comply with these standards.

Q5. Do you agree with the Legal and Policy Framework as set out in the policy?


6. Core Principles of Safe/Appropriate Handling of Prescribed Medications6.1. The Royal Pharmaceutical Society has identified eight core principles which relate to the safe handling

of prescribed medicines which should apply to all care settings:

people who use social care services have freedom of choice in relation to their provider of pharmaceutical care and services including dispensed medicines;

care staff know which medicines each person has and the social care service keeps a complete account of medicines;

care staff who help people with their medicines are competent to do so;

medicines are given safely and correctly, and care staff preserve the dignity and privacy of the individual when they give medicines to them;

medicines are available when the individual needs them and the care provider makes sure that unwanted medicines are disposed of safely;

medicines are stored safely;

the social care service has access to advice from a pharmacist;

medicines are used to cure or prevent disease, or to relieve symptoms, and not to punish or control behaviour.

6.2. All employees providing medication administration and assistance must adhere to these principles.

7. The Five ‘Rights’ of Medication Administration 7.1. Assisting with the management and administration of medication for individuals is an important part of

ensuring their wellbeing. Every care should be applied to ensure this is done safely and without error.

7.2. Five recognised principles should be applied as a checking system on every occasion that medication is administered to an individual.

Right Person the medication is for that specific individual

Right Medication it is the specified medication as designated by the prescriber

Right Time the medication being administered is given at the specified time as detailed by the prescriber

Right Dose the dose being administered is the correct dose as detailed by the prescriber

Right Route the prescribed medication is administered via the route indicated by the prescriber.


8. Administering Medicines to Individuals – the Legal Position and Attaining Consent8.1. Employees can assist individuals with medication, other than injections and inserting suppositories, if

the medicine has been prescribed for that person and the written directions of the prescriber are followed. These directions will be on the medicine label and the Medication Administration Record ( MAR) chart.

8.2. Individuals should where practicable retain /or be enabled to retain independence with all daily living skills including management of their medication.

8.3. Where it is established by appropriate assessment that the individual is not able to manage aspects of their medication then consent should be obtained by the service using the relevant Consent Form included in the Service Specific Guidelines.

8.4. Consent Forms must be updated with any change in needs, or annually at the specified review date.

8.5. An individual always has choice but there may be occasions where their right can be overruled; but there is a legal process to follow, which is outlined below. Where an individual has been formally proclaimed to lack the capacity to give consent, whether by physical or cognitive difficulty an appropriate representative such as Power of Attorney/Welfare Guardian can provide the written consent for support on that person’s behalf. This should be obtained prior to support being implemented.

8.6. Where an individual is deemed to lack capacity to manage their medication and consent to treatment by a GP, Psychiatrist or Psychologist and there is no appropriate representative then a Part 5, Section 47 certificate should be obtained by the assessor prior to support being implemented. The recommendations for treating adults with incapacity found in the Adults with Incapacity (Scotland) Act 2000, Part 5, Section 47 should be followed.

8.7. Under this part of the Act the Medical Practitioner (GP) has the authority to “do what is reasonable in the circumstances, in relation to the medical treatment in question, to safeguard or promote the physical or mental health of the adult”.

8.8. Consent should also extend to the disposal or destruction of medicines, as these remain the property of the person the medicines are prescribed for.

Q6. Do you agree with the Legal Position and Attaining Consent as set out in the policy?

9. Equality and Diversity9.1. The Equality Act 2010 places a duty on local authorities to eliminate unlawful discrimination,

harassment and victimisation; to advance equality of opportunity; and to foster good relations between people who share protected characteristics and those who do not share them.

9.2. To comply with this statutory duty the Council and Partners will:

provide a service that reflects the Council’s commitment to equality of access for all individuals, taking into account the needs of vulnerable groups;

take into account good practice which promotes equal opportunities and incorporate this good practice when reviewing and revising our policies and associated service procedures;

ensure that policies, procedures, service standards and information material are accessible to all our customers;

produce information in plain language that is clear and understandable to everyone and takes account of older people and people with learning disabilities;


Produce information in different formats and community languages on request.

9.3. Individual’s cultural and religious requirements should be fully and carefully considered and may include: vegetarians and people from some religious groups who do not want gelatine capsules (made

from animal products);

having medicines given to them by people of the same gender;

the administration of medicines during religious festivals, including fasting;

taking account of modesty and respect and other cultural practices including due regard for ‘unclean’ substances1.

Q7. Do you agree with the approach to Equality and Diversity as set out in the policy?

10.Roles and Responsibilities 10.1. Specific roles and responsibilities of employees in each service are outlined in the Service Specific

Guidelines.

Senior Managers and Corporate Responsibilities10.2. It is a corporate responsibility to collate and communicate consistently to all relevant personnel any

issues that arise which cannot be resolved locally.

Health Personnel10.3. General Practitioners (GPs) have a responsibility of care for all of their listed patients to provide

general health and medical care, or refer for specialist health care or social care.

10.4. In looking after an individual’s health and well-being, the GP or other non-medical prescriber will prescribe medication to their patient to prevent, treat or relieve medical conditions.

10.5. GPs are also expected to undertake medication review and identify any compliance problems. They are also responsible for providing medicines at the frequency most appropriate for the service user.

10.6. Within primary care, suitable qualified nurses or pharmacists are also able to prescribe.

Community Pharmacists10.7. Community Pharmacists have a professional responsibility to supply medication prescribed by GPs

and other recognised prescribers. The medication must be of a suitable quality and comply with legal and ethical requirements for the packaging and labelling.

10.8. Pharmacists also have a responsibility to ensure that the individual receives appropriate information and advice to support them in gaining best effect from any medicines supplied.

10.9. Responsibility for providing MAR charts rests with the care provider. Neither the pharmacists or/nor the dispensing GP is responsible but may be prepared to provide them on request.

Nursing Personnel10.10. Nursing Personnel will provide nursing and clinical care to individuals, which includes (not

exhaustively): Caring for wounds Care for pressure sores

1 See Supporting Individuals with Religious Beliefs Booklet


Changing of dressings Carrying out invasive procedures such as injections and bladder irrigations and matters relating

to feeding tubes

10.11. During such provision nursing personnel will also monitor the health status of the individual and report any changes in circumstances to the GP.

Specialist Nursing10.12. Specialist nurses support and educate individuals in coping with their particular condition and assist

them in dealing with equipment drug treatments or therapy necessary to their condition.

10.13. Specialist nursing includes (but not exclusively): Respiratory Nurses Stoma Nurses Palliative Care Nurses

Q8. Do you agree with the section on Roles and Responsibilities as set out in the policy?

11. Assessment Process11.1. As part of a referral for services individuals will be subject to a full assessment of their overall needs.

This assessment would include an accurate assessment of needs with regard to their medication.

This assessment must be undertaken by a suitably trained employee – details of which are outlined in the Service Specific Guidelines.

11.2. All aspects of the individual support needs with regard to their medication should be captured and incorporated into the individual’s Care and Support Plan.

11.3. Appropriate Risk Assessments (Appendix 1) should be completed and also incorporated into the individual’s Care and Support Plans.

11.4. The assessment should be conducted with the individual having full participation in the assessment process using appropriate methods of communication and support from their nominated representative where required.

11.5. The assessment should recognise and identify the individual’s preferred method of support, and recognise existing supports in place from family and friends. Further to this the assessment should incorporate information on the preferred pharmacy used by the individual, detailing the pharmacy name and contact details.

11.6. Specialist support tasks that are delivered by Health Professionals involved in the care of the individual should be accurately recorded and incorporated into the individual’s care and support plan.

11.7. The individual should be advised that as part of the provision of support services to assist with their medication needs that their consent or that of their nominated representative is vital to allow services to be implemented.

Q9. Do you agree with the approach to the Assessment Process as set out in the policy?

12.Service Specific Procedures - General Standards12.1. Within the Council, the manager with overall responsibility for each service is required to complete

and submit Service Specific Guidelines for agreement by the relevant Senior Manager. These guidelines must meet and comply with Care Inspectorate and other relevant guidelines and best practice.

12.2. While the Service Specific Guidelines will reflect the needs of each service, they must dovetail with each other so that an individual receives the same care regardless of which service they are using.


http://ww20.south-ayrshire.gov.uk/corporateservices/corporateresources/healthandsafety/Shared%20Documents/Risk%20Assessment%20Form.doc

12.3. Partners must have Guidelines / Procedures which are no less robust than the Councils, which will be ensured by using the Procedure Checklist outlined in Appendix 2.

12.4. For each area of service, procedures must be in place which outlines the approach to a range of issues, including:

Consent Recording Safe Storage Safe Disposal Refusal of Medication Adverse Reactions / Side Effects Covert Medication Missing Medication Medication Errors Individuals and Alcohol Mid-cycle and Discontinued Medication PRN (as required) Medication Prescribed Controlled Drugs / Illicit Drugs Variable Dose Drugs (eg Warfarin) Minor Ailments Self-Administering Transfer of Medicines Specialist Training Not able to Swallow Compliance Aids

Q10. Do you agree with the guidance on Service Specific Procedures - General Standards as set out in the policy?

13.Reporting Errors13.1. Employees should fully comply with the policy and this should minimise the potential for errors when

assisting with medication.

13.2. As highlighted in Section 12, Service Specific Procedures outline the action employees must take when an error is discovered. However, the recording and handling of incidents should involve the steps listed below which standardises the process across the service.

13.3. Over administration, omissions, dispensing and prescribing errors constitute “incidents” and as such need to be recorded using a South Ayrshire Council Internal Incident Report Form AR1 (shown in Appendix 3) and any other service specific form outlined in the Service Specific Guidelines. In addition to sending the AR1 form to Corporate Health and Safety, the responsible officer should also send the completed form (using CC function on the email) to XXXXXXXX (this will be set up shortly.

13.4. ‘Near misses”, defined as incidents where a mistake was made but was recognised and rectified before an actual error in administration resulted, should also be reported.

13.5. The Service Manager or their nominated representative will investigate any error or incident to determine the root cause of the error. This will allow the investigating officer to identify if systems errors, poor practice or non-compliance was the underlying cause of the error and help the Service Manager or their nominated representative determine if procedural change, policy change or further training for the individual or all employees is required.

13.6. Where it has been established that the error has been caused by an employee, the Service Manager or their nominated representative has discretion to decide if the employee is able to continue to assist with the management and administration of medication and/or if there is a need


http://ww20.south-ayrshire.gov.uk/corporateservices/corporateresources/healthandsafety/Shared%20Documents/Accident%20and%20Incident%20Report%20Form%20-%20AR1.doc

for disciplinary action.

13.7. If the employee requires further training, including observational assessment in the field, the employee’s competence should recorded prior to the employee being allowed to undertake support tasks independently again.

13.8. External regulatory bodies (eg Care Inspectorate, SSSC) should be advised if deemed appropriate by senior management.

Q11. Do you agree with the approach to Reporting Errors as set out in the policy?

14.Data protection/ Handling Confidential Information14.1. The Data Protection Act 1998 is the legislation which protects confidential information and this

places specific requirements on the Council with regard to the protection of confidential/sensitive information, storage and access to such information.

14.2. To comply with its duty under this legislation the Council and Partners will:

not disclose information that has been given to us in confidence without the express consent of the individual to whom the information is pertinent. Where the individual has an impediment to agreeing consent, their appropriate representative must agree to any information sharing;

control access to any personal information and will only share relevant information when interacting with other agencies;

respect an individual’s right to confidentiality in dealing with their information pertaining to their support needs with regard to management and administration of prescribed medication or associated care;

not discuss an individual’s medication and care support needs with any other party unless there is written permission from the individual/or appropriate representative to do so;

when handling confidential personal information will promote, support and protect the privacy, dignity and rights of the individual;

follow good practice guidelines with regard to information handling;

ensure individuals can access the information held on their file should they express the wish to do so;

investigate any breach of confidentiality and take appropriate action as is necessary where breaches are confirmed.

Q12. Do you agree with the approach to Data Protection / Handling Confidential Information as set out in the policy?

15. Indemnity Statement15.1. The Council will, subject to the exceptions set out below, indemnify its employees against liability at

law, in the pursuit of their duties on behalf of the Council whilst acting within the scope of their authority provided always that all policies and procedures are adhered to.

15.2. Employees must not administer prescribed medication where they are unclear about any aspect of the administration.

15.3. The indemnity will not extend to liability directly or indirectly arising from personal fraud, dishonesty, wilful negligence, deliberate wrongful act or criminal offences.


Q13. Do you agree with the Indemnity Statement as set out in the policy?

16.Compliance 16.1. South Ayrshire Council requires all employees and Partners involved with the management and

administration of medication to comply fully with their duties and responsibilities as detailed within this policy.

16.2. Any failure to do so may result in an employee’s action/inaction being construed as behaviour which could be deemed as gross misconduct.

16.3. All instances of failure to comply will result in investigation and possible action under the Council’s formal Disciplinary Policy and procedures.

16.4. Any failure on the part of a Partner who acts on behalf of the Council to comply with provisions of this policy, may invoke a review of the partner agency contract with the Council.

16.5. It is the responsibility of the Service Manager to ensure that all employees undertaking medication management tasks are trained to carry out these tasks and have these skills regularly updated.

16.6. Training for appropriate employees in all care settings will be provided to ensure that there is full knowledge of the guidelines and to enable full compliance.

16.7. No employee will be permitted to administer medication unsupervised unless they have been trained in the relevant procedures.

Q.14 Do you agree with the approach to Compliance as set out in the policy?

17.Complaints17.1. All complaints will be handled in accordance with the Council’s Listening to You complaints handling

process.

17.2. In terms of handling complaints, staff should first take steps to rectify the problem.

17.3. However, social care staff should refer any complaints that cannot be easily resolved to their manager.

17.4. The individual should be made aware of the Council’s Listening to You procedure.

Q15. Do you agree with the approach to Complaints as set out in the policy?

18.Monitoring and Evaluation18.1. The Council is committed to the continuing development of the policy and will endeavour to maintain

its accuracy and relevance

18.2. This policy and associated procedures will be reviewed on an annual basis for the first two years and then bi-annually after that.

18.3. The main elements to be included in the review will include:

Changes in National Policy, Directives and Guidelines Views of Service Managers about problems / challenges associated with the policy Feedback from individuals and/or carers Feedback from health and social care employees Review of Service Specific Guidelines Number of errors/complaints reported and remedial action taken


http://www.south-ayrshire.gov.uk/listeningtoyou/

Q16 Do you agree with the approach to Monitoring and Evaluation as set out in the policy?

19.Consultation Questions19.1. This is a consultation draft, which means it can be changed if it is not quite right. You can help

change this policy by giving us your comments.

19.2. You can give comments by answering the questions below and/or giving fuller comments. A copy of these questions are available at https://www.surveymonkey.com/s/HZH65ZR

Q1. Do you agree with the Purpose as set out in the policy? Yes No

Comments (eg anything you would add / change/ take out)

Q2. Do you agree with the Aims and Objectives as set out in the policy? Yes No


Q3. Do you agree with the Policy Scope as set out in the policy? Yes No


Q4. Do you agree with the Definition of Medication as set out in the policy? Yes No


Q5. Do you agree with the Legal and Policy Framework as set out in the policy?

Yes No


Q6. Do you agree with the Legal Position and Attaining Consent as set out in the policy?

Yes No



Q7. Do you agree with the approach to Equality and Diversity as set out in the policy?

Yes No


Q8. Do you agree with the section on Roles and Responsibilities as set out in the policy?

Yes No


Q9. Do you agree with the approach to the Assessment Process as set out in the policy?

Yes No


Q10. Do you agree with the guidance on Service Specific Procedures - General Standards as set out in the policy?

Yes No


Q11. Do you agree with the approach to Reporting Errors as set out in the policy?

Yes No


Q12. Do you agree with the approach to Data Protection / Handling Confidential Information as set out in the policy?

Yes No



Q13. Do you agree with the Indemnity Statement as set out in the policy? Yes No


Q14. Do you agree with the approach to Compliance as set out in the policy?

Yes No


Q15. Do you agree with the approach to Complaints as set out in the policy?

Yes No


Q16 Do you agree with the approach to Monitoring and Evaluation as set out in the policy?

Yes No


Would you like to add anything else?

Name

Position (if applicable)


Contact details

(if you would like feedback)

Please send comments by 16.08.13 to:

Ms Zhan McIntyre (Housing Policy and Strategy Coordinator)

Newton House

30 Green Street Lane

Ayr

KA8 8BH

[email protected]

01292 612916


mailto:[email protected]

Appendix 1 South Ayrshire Council Risk AssessmentReference No: Directorate:This risk assessment should be regularly reviewed as change in work activity / equipment / personnel / systems dictate. If no other changes occur then the activity should be re-assessed after a period of 3 yearsDescription Person(s) at Risk

Hazard(s) Types of Loss / Injury /Ill health e.g. Fracture/disease/psychological harm

Existing Control Measures

Risk Rating Number (RRN) with existing Control Measures: X =severity likelihood

HIGH: MEDIUM: LOW:High =20 to 36 Med = 9 to 18 Low = 1 to 8

Additional Recommended Control Measures: Action by: Completion Date:

RRN after implementation of additional control measures: x =(repeat RRN from above if no additional measure recommended) severity likelihood

Assessed by: Date:

Designation:

Person Responsible for ensuring the above is implemented:

Signature: Issue Date:

Designation: Review Date: Comments:


HEALTH AND SAFETY RISK ASSESSMENT GUIDANCEHazard Hazard is an event or situation, which has the potential to cause harm (loss, damage, injury,

ill-health, psychological harm, industrial disease or death)

Risk Risk is the chance, or likelihood, that the harm will occur from a particular hazard.

Examples (i) Faulty wiring is a hazard, which could result in the risk of electrocution or fire.(ii) Verbal or Physical Abuse is a hazard, which could result in the risk of injury and/ or

psychological damage(iii) Exposure to hazardous substances is a hazard, which could result in risk of ill health

or industrial disease

We require to estimate how likely a risk is to materialise and how severe the consequences might be, in order to prioritise the necessary preventative action.

QUANTIFICATION OF RISKEstimation of severityThe severity column should be used to estimate the severity of impact, should the risk arise.Estimation of LikelihoodThe likelihood column should be used to estimate the chance of the risk occurring.

Severity Likelihood1 Negligible 1 Remote Chance2 Minor 2 Unlikely3 Moderate 3 Possible4 Major 4 Likely5 Critical 5 Very Likely6 Catastrophic 6 Almost Certain

When selecting the “severity”, we need to consider how the risk would impact in terms of level of loss, injury or ill-health. We need to consider what is most probable, rather than what is possible.

When selecting the “likelihood”, we need to consider the exposure frequency, e.g. dealing with an aggressive customer, as a ‘one off’ is less likely to have an impact than being exposed to aggressive customers on a daily basis.

Risk Rating = Severity x LikelihoodThe Risk Rating Matrix outlined below is a tool with which the risk rating can be classified, and is accepted as a means of analysing South Ayrshire Council Health and Safety Risk and whether this is considered to be HIGH, MEDIUM or LOW. Risks rated at 9 or above require to be addressed, in order that they can be reduced to the lowest level reasonably practicable. Those below 9 should be continually monitored, (and addressed where resources permit). Risk Rating Matrix


High 20 to36

Risks not acceptable under any circumstances. Immediate risk reduction required.

Med 9 to 18 Risk reduction measures required.

Low 1 to 8

Address where resources permit and continue to monitor regularly, as risks can increase over time.

36 30 24 18 12 6

30 25 20 15 10 5

24 20 16 12 8 4

18 15 12 9 6 3

12 10 8 6 4 2

6 5 4 3 2 1

Appendix 2 Service Specific Procedures ChecklistName of ServiceName of person completing checklistDate

Standards and Principles

Yes / No / Somewha

t / NAComment

Complies to the Principles of National Care StandardsComplies to Core Principles of Safe/Appropriate Handling of Medications outlined in SAC Medication Administration PolicyOutlines system used to ensure the monitoring of the training of employeesSets out clearly how consent will be obtained and renewed

Training and ComplianceOutlines procedure for new staff trainingOutlines procedure on how staff will be trained / monitored / reviewed / observed

General StandardsOutlines approach to Assessment and Support LevelsOutlines approach to Assessing Capacity and recording ConsentOutlines approach to Recording of medicinesOutlines approach to safe storage of medicinesOutlines safe disposal procedures of medicinesOutlines approach to refusal of medicationOutlines approach to dealing with reactions / side effects of medicinesOutlines approach to covert medicationOutlines approach to missing medicationOutlines approach to medication errorsOutlines approach to individuals and alcoholOutlines approach to Mid-Cycle and Discontinued MedicationOutlines approach to PRN (as required) MedicationOutlines approach to prescribed Controlled Drugs / Illicit DrugsOutlines approach to Variable Dose Drugs (eg WarfarinOutlines approach to planned absence from homeOutlines approach to individual admission to hospital / respiteOutlines approach to treatment of minor ailmentsOutlines approach to self-administering


Outlines approach to transfer of medicinesOutlines approach to specialist trainingOutlines approach if individual is unable to swallowOutlines approach to compliance aids

DeterminationMeets standards – no further actionMeets standards with minor changes Meets standards with major changes Fails to meet

Recommendations / Actions

Deadline for action

Name of Assessor RoleDate


Appendix 3 Example of South Ayrshire Council Internal Incident Report Form

FORM AR1 SOUTH AYRSHIRE COUNCILINTERNAL INCIDENT REPORT FORM

OFFICE USE ONLY

Code:

InvestigationDate:

To be completed in accordance with SAC Incident Reporting & Investigation Standard for all work-related incidents occurring within Council controlled property, involving Council employees, persons under the supervision of the Council, contractors or other members of the public. Complete all sections in CAPITALS and in black ink. Send the completed original AR1 Form to Corporate Safety Team and retain a copy for your own records.

DIRECTORATE: SERVICE: REF: A - INJURED PERSON’S DETAILS (if relevant)

Full Name: Work Base:

Home Address: Address:

Postcode: Tel: Occupation:

Date of Birth: Age: SEX:

M F Status: Council Employee Member of Public

Employee under18 Contractor

Client/Pupil Other

Employee No: Contractor Name:

N.I. Number: Nature of Contract:

B-1- INCIDENT DETAILS (e.g. injury, wilful fire raising, etc)

Location of incident: Location Address: Date of Incident:

Telephone: Time of Incident: 24hr clockPostcode: Council Property: YES NO Reported to:

Date Reported: Designation: Nature of Injury: (e.g. broken bones, cuts, lacerations, bruises - Include part and side of body affected): B-2 Has Employee been off work for more than 3 days due to the incident including weekends, holidays or rest days but not counting the day

of the incident itself, or in the case of a Non-Employee, if they have been taken from the incident directly to hospital.No Absence: Employee Absent over 3 Days: Employee in Hospital over 24 hrs: Non-Employee taken directly to Hospital:

WHAT HAPPENED? Include details of what was happening just prior to the incident, what actually happened and the consequences as a result of the incident. Continue on a separate sheet if necessary.

Safety Equipment, Plant used, PPE worn at incident (if relevant):

Signature of Injured Employee (if available): Tick if completed Witness Statement Form(s)(WS1) and Incident Investigation Form (IF1) are attached.C-1 - RESPONSIBLE PERSON (e.g. Supervisor, Manager etc) (RETURN TO CORPORATE SAFETY WITHIN 5 DAYS)

Name: Work Address: Designation:

Work Base: Telephone:

Actions taken to prevent recurrence: (Changes in systems, training needs identified, maintenance / repairs made etc.):

C-2 Are you satisfied that the incident happened in the course of the individual’s employment with South Ayrshire Council? YES NO (If NO, in the case of an employee, please comment on a separate sheet)Signature of Responsible Person: Date:

D - RIDDOR 1995 (For Office Use Only) Attach associated forms

RIDDOR Incident No: NOTES: DATA PROTECTION INFORMATION This form will be used for the purposes of investigating your incident, the monitoring of occupational and injury related absence and ill health within the organisation and the resolution of any civil or criminal legal action arising out this incident. It may be accessed by the following: Health and Safety professionals Occupational Health professionals, Trades Union Health & Safety Representatives or non-union Employee Representatives of Health and Safety Risk Management staff, Insurance Staff, the Council’s Insurers and appointed Legal professionals, Enforcement Agencies (such as the Health and Safety Executive, Employee Medical Advisory Service, Fire Authority, Environmental Health) Departmental staff involved in any such investigation and subsequent implementation of remedial measures as appropriate Access to this information by any other person will only be with your written consent. You are entitled to a copy of this form.


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