The evening staff went and night staff together with the evening nurse had a port handed over, both in writing and verbally as per the policy to keep a good quality of care they have at work and also the health and safety act 1974. After the handover me and the evening nurse went to see one of the resident who was poorly to have an as correct handover as possible to be able to identify any changes as quick as possible. I was planning to phone the family before 1 1 pm to give an update of the state of their relative.
Then I was handed over the keys, as it in only the URN who are allowed the keys according to policy and the Misuse of Drugs Regulations 2006 and Controlled Drugs Supervision of Management and use) as for England. Misuse of Drugs Act 1971. After I have gone around and done a check and answered a few call bells I started preparing to hand out the night time medication. I unlock the door to the drug room and take out the looked trolley which contains the residents drugs. Made sure had clean pots and spoons and straws. All rooms had a jug with fresh water and a suitable container to drink from.
NC has standards for medication management which had to follow as well as regulation 13 of the Health and Social Care Act 2008 and my code of conduct. During the drug round I tried not to be too disturbed but did answered call bells during the drug round. For each and every patient checked date and time on mar sheet and double checked it was the right patient and checked the date on the box or blister to see that the medication was not expired. Check the dosage and admit way. Trying to be up to date in my knowledge by reading on MIRA web site. Also checked how the medication had been documented over the day, were they refused?
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When was the last dose of the same medication he or she has before bed time? Is the resident sitting up properly to be able to swallow the medication? Are there enough water in the jugs? During this time I also checked how the patient were feeling by talking to them. Were they talking as normal or was their speech slow or different? How is there breathing? Are they warm enough, do they look ill, do they have a temperature? Is the catheter draining? Do they need any PRNG drugs? Constipated or in any pain? Then I signed the mar sheet to confirm that the resident had taken his medication or signed for any refusal or other reasons.
When it was time to give the controlled drugs. I called one of the senior staff to come with me to get the drugs in a special locked area assigned for controlled drugs. I took the CD signature book and with the other staff checked the drug for expire date, name, strength admit way, and sign in the book. Then we went to the patient, both of us, and gave the patients its medication. Was an oral administer way so we stayed while she swallowed the medication. ( This is regulated as well by the regulations and guide lines as I had when was handing out the medication.
MIRA and ICQ are 2 body which can control the management of controlled drugs and to check so all guidelines, legislations and code of conduct are followed. When all the residents had had their medication, I went one more time to check so they were okay. Then I checked with the staff to get a rapport about any issues or problem I should know about and then I took my coffee to do the documentation. Overall documentation was made and I also made sure any general information was documented and brought forward like bath requests, visitors, out goings and appointments.
There was 2 kind off drugs which needed to be ordered in the morning so these was written up as well. Documentation is of high importance because it gives evidence of quality and that all legislations and human right are followed as mental capacity act, confidentiality, quality of care and that care plans are followed as well as patient's safety and consent. At my workplace we document in a computer system and have care plans in a person folder in case we cannot access the information on the computer. To easy overview changes in care we have a ay to day based handover sheet as well.
ICQ regulates that the documentation is correct done and they have a minimum standards that the nursing home need to apply to. When it was an appropriate time, a senior staff and me checked and counted the controlled drugs (that are not in daily use) and signed that they are correct as I am responsible to do according to Misuse of Drugs Regulations 2006 and Controlled Drugs (Supervision of Management and use) as for England, the ICQ guidelines and code of conduct and NC standards. During the night helped a few residents to the oiled according to the care plan and the manual and handling act and I made sure I had their consent first. Also checked the residents regardless, once an hour, but it always became more often as I checked the other resident at the same time as someone rang the call bell. Some residents needed to be turned regular ( the carnelian will tell me how ( manual handling)and how often and why). During the shift I also checked so the staff was fine and if they had anything to rapport to me or have had any problems during the shift so far, and so they follow policies and procedures for the workplace and annual handling act and following the care plan.
I did this by working with them and checking residents regularly to see if they were turned, dry, offered a drink if awake and had their call bell with in reach. The staff called me because a dressing had come off on a residents foot. I looked in the care plan to see what actions and what dressing they have had applied on the wound and re dressed it and then documented it in the care plan. I had to do a phone call to this patient's family to give an update of how their loved one was progressing.
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