Refused medicines in social care – when should you give medicines covertly?

Firstly, care staff should use their MAR charts or eMAR to record the person has refused their medicines and record the reason why (assuming one has been given). The situation should be monitored to see if it is a frequent or recurring incident (electronic medication management can help with this).

In cases where refusals are frequent or recurrent, or where refusals represent a risk to the person’s health then you should ask the prescriber to review their treatment, as an alternative, perhaps more tolerable medicine may be available.

Care workers should be on the lookout for reasons why a person might not be able to give the necessary consent to take their medicines, for example:

• Mental health problems including anxiety
• Cultural differences/beliefs
• Poor understanding of what the medications are for
• Vision or hearing problems
• Difficulty understanding English
• Issues with the medication itself, such as unpleasant side effects

The steps to giving medication covertly

Additional to the possible reasons above, care workers should also be watchful for signs that might indicate a person’s lack of capacity to make decisions about their care.

A clear process should be in place for care staff to raise concerns that a person lacks this capacity. All care staff should be reviewed to ensure they know the signs of a lack of capacity and the process to follow if they spot those signs.

The process to determine that a person can be given medicines covertly should be included in your medicines policy and procedures.

Firstly, when concerns are raised, an appropriate person, for example, the prescriber, should carry out a mental capacity assessment.

The outcome and elements of this assessment, as well as who carried it out, where, when and so on must all be recorded and the outcome and any resulting changes must also be added to the person’s care plan. As with any care plan change, but especially in regards to mental capacity and medicines, these changes need to be made to all versions of the care plan that exist, with immediate effect.

This is a non-issue if you use electronic care plans and records, but if you still using paper records then you will need a plan in place to make these updates fast and avoid having contradictory versions of care plans and other records floating around. 

If the person is judged to not have the capacity to make decisions about their medicines, you should arrange a best interests meeting.

This meeting should include:

• The prescriber
• Care staff
• Pharmacist
• A family member of the person who can represent the person’s interests
• OR an attorney appointed for health and welfare decisions
• OR an Independent mental capacity advocate (IMCA)

This group should work together to decide whether it is in the person’s best interests to stop the medicines, give them in a different form or to give them the medicines without their knowledge.

Its vital that you check whether a person has recorded an advanced decision that governs whether they can be given any medicines should they lose the capacity to make decisions in the future.

Unless it is agreed at one of these meetings, medicines should never be given without a person’s knowledge.

As with the capacity assessment, the people present, their roles and the decisions made at the meeting all need to be recorded. The person’s care plan also needs to be updated to reflect any decisions made.

Care staff who deliver care, who are involved with delivering care to the person must be made aware, clearly, if they are now authorised to give medicines covertly to the person.

You should then work with or seek advice from a pharmacist on how to give any of the medicines covertly and make sure there are measures in place to ensure that medicines put in food or drinks cannot be consumed by another person, this is especially true in residential care settings.

Continual review

You need regular reviews with staff and people you care for. Firstly, people’s capacity to make decisions about their care can change over time, and in both ways. People’s health and wellbeing can improve. Secondly, you need to ensure your care workers have the right training and knowledge about how best to give medicines covertly and that they are well versed in your medications policies and procedures that govern these areas.

Read more guidance on how you can manage medicines more safely and effectively in your care or nursing home