Last reviewed 6 February 2018
Martin Hodgson explains recent guidance published by the National Institute for Health and Care Excellence (NICE) on the administration of medication in community care settings.
NICE guidance NG67, published in March 2017, includes advice for service providers in many aspects of medicines management, including the use of covert medicines. What does the guidance say and what is best practice in respect to the covert medicine use?
What is covert medication administration?
In adult social care, the provision of support with the taking of medication is nearly always done with the explicit consent and agreement of the service user concerned.
However, covert administration refers to rare occasions where medication can be given to a service user without their consent, often disguised in their food or drink. The method is used as a last resort where a service user refuses medication and is unable to give informed consent because they cannot understand what they are being asked and where their GP or doctor believes that their health would suffer without the medication.
To prevent abuse, the use of such covert medication administration methods must be subject to appropriate governance by social care providers and carried out within a clear ethical framework.
Supporting people to take their medicines
The NICE guidelines define medicines “support” in domiciliary care as helping service users to self-administer their medicines themselves or actually administering their medicines for them. In domiciliary care, help may include such things as reminding someone it is time to take their medicines, helping them to open a bottle of pills or actually giving them their medication.
The NICE guidelines state that domiciliary care workers should only give a medicine to a service user if:
there is authorisation and clear instructions to give the medicine, for example, on the dispensing label of a prescribed medicine
the six R’s of administration have been met
the care worker has been trained and assessed as competent to give the medicine.
The six rights (R’s) of administration are described as:
the right person
the right medicine
the right route
the right dose
the right time
respecting the person’s right to decline.
Care workers are advised that they should only provide the medicines support that has been agreed and documented in the provider’s care plan.
When a service user declines to take a medicine, care workers are advised to consider waiting a short while before offering it again. However, where a service user refuses to take a prescribed medication, and the prescriber believes that this may harm their health, covert administration may be considered as a last resort.
Giving medicines to people without their knowledge
The covert administration of medicines is covered in section 1.8 of the NG67 NICE guideline. The guidance states that:
domiciliary care providers must ensure that covert administration of medicines only takes place in accordance with the requirements of the Mental Capacity Act 2005 and associated good practice frameworks to protect both service users and care workers
care workers must not give, or make the decision to give, medicines by covert administration, unless there is clear authorisation and instructions to do this in the service user’s care plan, in accordance with the Mental Capacity Act 2005.
The guidelines also state that providers must ensure that the process for covert administration clearly defines who should be involved in, and responsible for, decision-making, including:
assessing a person’s mental capacity to make a specific decision about their medicines
seeking advice from the prescriber about other options, for example, whether the medicine could be stopped
holding a best interests’ meeting to agree whether giving medicines covertly is in the person’s best interests
recording any decisions and who was involved in decision-making
agreeing where records of the decision are kept and who has access
planning how medicines will be given covertly, for example, by seeking advice from a pharmacist
providing authorisation and clear instructions for care workers in the provider’s care plan
ensuring care workers are trained and assessed as competent to give the medicine covertly
when the decision to give medicines covertly will be reviewed.
Where necessary, advice should always be sought from the prescriber or from a pharmacist. The prescriber may be able to consider other options, for example, whether the medicine could be stopped or given in a different form.
Only medication which is considered essential for the service user’s health and wellbeing, or for the safety of others, should be considered to be administered in a covert way. Medication should never be administered in a covert way merely for the convenience of staff or as a form of control.
Any domiciliary care service which supports the administration of medication, including covert medication techniques, should have a written policy. The policy should state that:
under normal circumstances all medication should be administered with the full knowledge and consent of service users and every effort should be made by staff to obtain that consent
covert medication should only be used when the service user lacks the capacity to consent and is refusing treatment which has been deemed to be essential for their health and wellbeing
covert medication should be seen as a last resort and as an emergency procedure, rather than routine.
The NICE guidelines state that, when considering or administering covert medication, providers must act in accordance with the requirements of the Mental Capacity Act 2005 and associated good practice frameworks.
An assessment of mental capacity, as specified in the Mental Capacity Act Code of Practice, should always be completed before the use of covert medication is considered.
Every effort should be made to explain the need for the medication to the service user and gain their consent. Those who are shown to have mental capacity and still refuse a medication should have their refusal respected.
Medication should only be given in a covert way if the mental capacity assessment shows it is in the service user’s best interests and represents the minimum possible restriction of freedom. Best practice in the application of mental capacity law states that such decisions should be multi-agency and multi-disciplinary wherever possible. This is best to protect all those involved. Meetings to decide on the best interests of the service user should involve their family, advocate or legal representatives, the health professional prescribing the medicine and a pharmacist.
A lack of capacity should never be assumed and it should be remembered that lack of capacity is decision-specific and can be temporary. All best interests’ decisions should, therefore, be regularly reviewed.
Covert medication methods
When medication is given in a covert way, it must always be administered in a way that is safe and in line with best practice.
Details of any required covert administration should be clearly entered in the plan of care, including the method of administration. Care staff administering the medication should keep careful records of all doses given.
In many cases, covert medication can safely be given by placing it in a service user’s food or drink. However, staff should never crush tablet or capsule medication and mix it in with food or drink in order to administer it unless instructed by a pharmacist. Crushing may alter the properties of the tablet or capsule causing the resident to absorb the medication quicker than intended and suffer side effects. A pharmacist is in the best position to advise on the suitability of methods of administration. Any advice should be documented in the care plan.
Care staff should be suitably trained and experienced in the method of administration involved.
Adult social care providers in England must comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in order to maintain their registration with the Care Quality Commission (CQC). These include Fundamental Standards below which care must not fall.
Regulation 12, Safe Care and Treatment, includes a requirement for the “proper and safe” management of medicines and for sufficient medicines to be made available to meet service users’ needs and ensure their safety.
Since October 2014, a five key-question test has been used during CQC inspections in England in order to determine published ratings for each provider. Inspectors use Key Lines of Enquiry, Prompts and Ratings Characteristics for Adult Social Care Services when making their judgments.
Inspectors are prompted in the guidance to ask whether there are clear procedures for giving medicines covertly, in line with the Mental Capacity Act 2005. Inspectors are encouraged to look for evidence that the service follows correct procedures to protect people with limited capacity to make decisions about their own care, treatment and support, when medicines need to be given without their knowledge or consent, or when people require specialist medication.
NICE guideline NG67, Managing Medicines for Adults Receiving Social Care in the Community, can be downloaded from the NICE website.
In Scotland, Covert Medication Good Practice Guide, written by the Mental Welfare Commission for Scotland, provides practical guidance.