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Medicines

Key Line of

Enquiry (KLOE) &

STOMP-LD

Laura Picton

Learning Disability Provider Forum

20th November 2017

Our purpose

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• Register

• Monitor and inspect

• Use legal powers

• Speak independently

• Encourage improvement

• Outstanding, Good,

Requires Improvement,

Inadequate

• We make sure health and social care services provide

people with safe, effective, compassionate, high-quality

care and we encourage care services to improve

• People have a right to expect safe, good care

from their health and social care services

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Community social care services

• Community social care services (supported living and

Shared Lives) were rated the best overall when compared

with other ASC services

• Analysis of our inspections shows that there is variation in

performance depending on the size of services.

• Smaller homes are often for people with a learning

disability, and these services tend to perform well – they

have around half the proportion of inadequate or requires

improvement overall ratings compared with services

without a learning disability specialism.

• Caring and responsive key questions were particularly

strong, showing that providers are organising their services

to meet people’s needs, and staff are involving people in

their care and treating them with compassion, kindness,

dignity and respect.

New key lines of enquiry

To focus our inspection, we use a standard set of key lines of

enquiry (KLOEs) that relate to the five key questions

KLOEs support consistency of what we look at under each of the

five key questions and focus on those areas that matter most

KLOEs are supported by guidance on the key things to consider as

part of the assessment; these are called prompts

Each KLOE has a defined set of ratings characteristics – what does

‘good’ look like?

S4: How does the provider ensure the proper and safe use of

medicines?

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Medicines key lines of enquiry

S4.1: Is the provider’s role in relation to medicines clearly defined and described in relevant policies, procedures and training? Is current and relevant professional guidance about the management of medicines followed?

• Policies should be service specific, reflect practice be in date, read by and accessible to staff

• NICE guidance - SC1 for care homes and NG67 for people living in their own homes

• Appropriate training and support including an annual review of their knowledge, skills and competencies

• Providers must have robust processes for medicines-related

safeguarding incidents and should have robust processes for

identifying, reporting, reviewing and learning from medicines-

related problems.

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Medicines key lines of enquiry

S4.2: How does the service make sure that people receive their medicines (both prescribed and non-prescribed) as intended (including controlled drugs and as required medicines), and that this is recorded appropriately?

• Medicines records – MARs, controlled drugs, topical

• Treatment of minor ailments

• Additional guidance for when required medicines and those with variable doses

• What adjustments are made for time sensitive medicines?

• Compliance aids vs original packs 6

Medicines key lines of enquiry

S4.3: How are medicines ordered, transported, stored, and disposed of safely and securely in ways that meet current and relevant regulations and guidance?

• Secure or controlled access to medicines

• Risk assess storage

• Responsibility for ordering and collecting medicines

• Safe disposal of unwanted medicines – controlled drugs

• Suitable temperature for storing medicines

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Medicines key lines of enquiry

S4.4: Are there clear procedures for giving medicines covertly, in line with the Mental Capacity Act 2005?

• Assessment that person lacks capacity to make decisions about medicines

• Best interest meeting to consider each individual medicine – should be the last resort

• Discussion with pharmacy about how to administer safely and ensure continued effectiveness

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Medicines key lines of enquiry

S4.5: How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

• Inappropriate use of sedation

• Psychotropic medicines for people with learning disabilities – STOMP-LD

• Good care planning to anticipate behavioural patterns and environmental adjustments

• Records, care plans and staff guidance

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Medicines key lines of enquiry

S4.6: How do staff assess the level of support a person needs to take their medicines safely, particularly where there are difficulties in communicating, when medicines are being administered covertly, and when undertaking risk enablement assessments designed to promote self-administration?

• Medicines support – person centred, medicine specific

• Assumption that people can self-administer unless preference or risk assessment says otherwise

• How do staff decide if a person needs to be given their medicines covertly? Is it always a last resort?

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Medicines key lines of enquiry

S4.7: How does the service engage with healthcare professionals in relation to reviews of medicines at appropriate intervals?

• Supporting people to attend appointments and reviews

• Contacting the GP to arrange a medicines review

• Knowing when to refer to healthcare professionals

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Medicines key lines of enquiry

S4.8: How do staff make sure that accurate, up to date information about people’s medicines is available when people move between care settings? How do medicines remain available to people when they do so?

• Medicines reconciliation

• New medicines

• Entry into new care services

• Discharge from hospital

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Background

S4.5: How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

Reports published in 2015 following the investigation into Winterbourne View found that:

• There is a much higher rate of prescribing of medicines associated with mental illness amongst people with learning disabilities than the general population, often more than one medicine in the same class, and in the majority of cases with no clear justification;

• Medicines are often used for long periods without adequate review, and;

• There is poor communication with parents and carers, and between different healthcare providers

The core message

• Public Health England say every day about 30,000 to 35,000 adults with a learning disability are being given psychotropic medicines when they do not have a diagnosed mental health condition.

• This is often to manage behaviour which is seen as challenging. It includes medicines used to treat psychosis, depression, anxiety, sleep disorders and epilepsy medication when it is only used for its calming effect, rather than to treat epilepsy.

• Unnecessary use of these drugs, puts people at risk of significant weight gain, organ failure and premature death.

www.england.nhs.uk/STOMP

STOMP-LD aims

1. Improve the quality of life of children, young people and adults with a learning disability, autism or both, who are prescribed psychotropic medicines.

2. Make sure people are only given them for the right reason, in the right amount, for as short a time as possible.

3. Improve everyone’s understanding of these medicines and give everyone the confidence to ask why they are needed.

4. Improve understanding of non-drug treatments and support which may help.

5. Make sure the person with their family and paid carers are involved in any decisions to start, stop, reduce or continue taking them.

NICE NG11

Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges

States that the use of psychotropic medication should be the last resort for managing behaviour which challenges and should only be considered if:

• Psychology or other therapies do not help within an agreed timeframe

• Treatment for a mental or physical health condition has not improved the behaviour

• The risk of harm to the person or others is very severe

Best Practice

Within social care providers, VODG has examples of:

• best practice

• practical ideas for implementation

• self-assessment tools

• action planning

• information share

https://www.vodg.org.uk/campaigns/stompcampaign/

Best practice examples

• Actively promoting alternatives to medication such as active support, intensive interaction or positive behaviour support.

• Ensuring the people, and their circle of support, are involved in decisions about their care, including their medicines.

• Ensuring all staff have an understanding of psychotropic medicines, including its main uses and side effects.

• Encouraging staff to speak up if they have a concern that a person we support may be over-medicated.

Best practice examples

• Maintaining accurate records about the health, wellbeing and behaviour of people supported.

• Supporting people to have regular reviews of their medicines.

• Monitoring the use of psychotropic medicines.

• Working with people with a learning disability, autism or both, their families, health professionals, commissioners and others to stop over-medication. This includes working closely with prescribers.

Case Study A

• Female in her late forties

• Long term history of behaviour which staff found challenging and where increasingly difficult to support

• Moderate learning disability, autism and epilepsy

• Prescribed:

- 5 antipsychotic medicines

- 2 medicines for epilepsy

- Further medicines for hypertension, osteoporosis and hypothyroidism

• Administered 69 doses of lorazepam in the month prior to referral to a new unit for severe anxiety

Ref: CMG STOMP Best Practice Guide 31.05.2017

Case Study A

• Results of a 6 week assessment found her to have poor physical health and to become increasingly distressed when prompted by staff to have personal care.

• She was reacting in a distressed way to noise and was not communicating as effectively when distressed as she was able when calm.

Case Study A

Actions taken:

• Staff training on total communication, active support and person centred planning

• Positive Behavioural Support plan written to include noise reduction by changing accommodation and helping A to use visual aids to communicate

• Full health review and changes to personal care

• Recording mood on a 5 point scale

Case Study A

Outcomes:

• Reduction of 97% in total lorazepam dose after 6 months

• Reduction of mood score 5 (extremely distressed) from 40% of time to under 1% after 10 months

• Medicine review – reduced one anti-psychotic and one anti-convulsant medicine

• Increased confidence and independence

Case Study R

• 55 year old male living in a supported living service

• Prescribed psychotropic medicines due to incidents of challenging behaviour

- Olanzapine 10mg daily

- Chlorpromazine 700mg daily

- Clopixol 70mg daily

- Procyclidine 15mg to treat side effects

• Recent mobility problems and several falls led to referral to a psychiatrist to review medicines

Case Study R

• Olanzapine gradually reduced then discontinued

• Immediate improvement in mobility and cognitive ability

• Further reductions in chlorpromazine and procyclidine – monitored and reduced slowly

• Supported by a mood chart for staff to record how R was coping with emotions and engagement in activities.

• R completed a self-help diary and reflected with his keyworker weekly to identify best coping strategies

How can you show us that you support STOMP-LD pledge

Staff:

• Understanding of psychotropic medicines

• Ability to recognise side effects

• Willingness to speak up if they felt a persons behaviour was being controlled by excessive or inappropriate medicines

• Training to support people with behaviour that challenges - Skills for Care workforce development resources

How can you show us that you support STOMP-LD pledge

Records:

• Is the reason for prescribing a psychotropic medicine clearly recorded?

• Is their detailed guidance available to staff to identify when a medicine prescribed to be given when required may be needed?

• Are medicines given ‘off-label’ or outside of their recommended dose range? Do staff understand their responsibilities when giving medicines in this way?

• Are consent to treatment procedures or best interest decisions followed and recorded?

• How are people, their families and carers involved in decisions about their care, including medicines?

How can you show us that you support STOMP-LD pledge

Review:

• Do staff assess a person’s response to treatment and any side effects?

• Is there a regular review and evaluation of the continued need for psychotropic medicines?

• How does the provider work with others to stop overmedication?

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Thank you

www.cqc.org.uk

enquiries@cqc.org.uk

@CareQualityComm

Laura Picton

www.england.nhs.uk/STOMP

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