First Aid, Home Remedies and Medication

The Home must have a qualified First Aider on duty at all times.

First Aid boxes should have a white cross with a green background and must be held in the  Home and should be carried in each of the vehicles used for the transportation of children.

Each box has an inventory that must include the full quantity of each item stipulated in the box. When an item has been used, then it should be replaced as soon as possible.

Recording: Each child should have permission for staff to administer first aid and non-prescription medication from a person with Parental Responsibility for them recorded in the relevant plan. Permission should be sought and arranged by the child's social worker.

The administration of First Aid must be recorded in the First Aid Log, Accident Book (if there has been an accident), individual child's Daily Record and Medication Administration Record (MAR).

Medications will be reviewed in line with the practitioners guidance.

A specialist allergy nurse/consultant will help develop a Health Care plan which should be shared with all agencies working with the child/young person.

The Care and Placement Plan and Health Care Plan should contain the following:

• All known allergies and associated risks including spotting the signs and symptoms of an allergic reaction and anaphylaxis for the child/young person;
• Preventative measures should be detailed in the Plan - for example taking daily antihistamines for hay fever, making sure cleaning products and gloves are hypoallergenic, and washing powder is suitable for skin conditions;
• Actions to take when a young person has an allergic reaction. The plan should describe exactly what to do and who needs to be contacted in the event of an emergency. For example, when to use an EpiPen and calling for an ambulance;
• All staff should be aware of the Plan and should have been trained to administer an EpiPen by a suitable qualified health professional;
• The child/young person should be educated around their allergies and what to do in an emergency - a young person may be able to self-administer their own EpiPen or take antihistamines. If this is the case this should be recorded;
• Medication should be easily accessible so staff and/or the child/young person can access their medication in an emergency situation;
• A record should be kept of each episode and any medication given should be recorded on Medication Administration Record (MAR) sheet.

For further information, please contact the child or young person’s health professional who deals with their allergies and check the NHS website or see Allergy UK Website.

Home Remedies are medicines that can be bought over the counter, including Paracetamol*, aspirin, homeopathic, herbal, aromatherapy, vitamin supplements or alternative therapies.

Home Remedies can only be used by the young people in the home with the approval of relevant social workers (as set out in children's Placement Plans) or as prescribed by a GP.

Home Remedies should be purchased for a named individual child.

When a Home Remedy container is opened, staff should record the date of opening to ensure it is not kept beyond its expiry date.

No child may be permitted to 'self-administer' Home Remedies unless approved by their social worker, with the arrangements outlined in the Placement Plan.

Consideration should be given as to how long a child continues to use Home Remedies before they arrange to see their GP.

Recording: The administration of any Home Remedies must be recorded in individual child's Daily Record and Medication Administration Record (MAR).

*Paracetamol must not be given for more than two consecutive days without the approval of a GP/Medical Practitioner.

It is a legal requirement for care home records to be retained within the home even when a child has left the home. These records will be retained for a minimum of 75 years from the child's date of birth. If the child dies before attaining the age of 18, for 15 years from the date of the child’s death.

Each home should keep the following records:

Caption: Each home should keep the following records

Record	Purpose
First Aid Log	To record any administration of First Aid.
Accident Book	To record any accidents.
Medical Record	Individual record for each child, details of health related issues, medication used, name of GP.
Medication Administration Record (MAR)	Individual record for each child to record any medication (or Home Remedies) administered etc.

For detailed information about controlled drugs (such as morphine, pethidine, methadone and Ritalin) see CQC information on Controlled Drugs.

Medication

All medicines must be administered strictly in accordance with the prescriber's instructions (or as advised on the packet in relation to Homely Remedies). Only the prescriber (e.g. GP) can vary the dose. Medicines must be locked away in the locked storage areas when not in use. Before administration, staff should:

• Wash their hands;
• Make sure they have a pen and any required record sheets;
• Enough glasses for each young person receiving medication;
• A jug of water.

The procedure for administration is as follows:

• Check the young person's identity (a photo is normally kept in the young person's file). Only one young person should be administered medication at a time, this reduces the risk of mistakes being made;
• Check the young person's medical profile;
• Check the medication on the individual medication records corresponds with that on the young person's medical profile;
• Check the Individual medication record sheet to ensure that someone else has not already given the medication;
• Check the expiry date and use by date (where appropriate) on the medication;
• Check the amount to be given at that time;
• If opening a new container, add the date;
• Measure or count the dose without touching the medicine;
• If the medicine is a solid (such as a tablet) then carefully place into an appropriate container and offer to the young person. They may wish to put it in their hand or swallow straight from the container;
• If the medicine is a liquid, take care not to drip onto the label. If the amount to be measured is less than 5ml, then use a medicine syringe otherwise use a medicine spoon or measure as preferred by the young person;
• If the medicine is a cream or ointment, then it should be squeezed directly onto the young person's finger for them to apply. If required to be applied by staff, then latex/pvc gloves must be worn;
• When administering a Controlled Drug, a second member of staff, must check the dose prior to it being administered;
• Watch the young person as they take their medicine to ensure administration is successful;
• Offer the young person a drink of water (where appropriate);
• Check that the medication is recorded in all the required records;
• Print and sign your name against date and time of each medicine administered;
• Record when medicine has been refused / not taken and the reasons why;
• If a young person is absent when medication is due- this should be recorded;
• Do not sign for any medicines that you have not administered or witnessed yourself;
• If a young person refuses to take medication, under no circumstances should they be forced to do so;
• Medication must be kept in the original labelled (by the Pharmacy) containers and not put into weekly/daily medical boxes;
• After administration the medicines should be returned to the cabinet immediately and the cabinet locked;
• Each time you give medication, remember that it is important to consider the time of administration. Care should be taken to ensure that if the medicine is required to be taken before food, that this is done. Similarly the administration of some medicines such as eye drops or inhalers may not be suitable to be given at meal times. Not all medicine administration times will fall in line with meal times.

Swallowing Problems

Staff may find that some young people may struggle with swallowing their medicines. The young person's G.P. should be contacted for an alternative. Under no circumstances should staff take it on themselves to crush tablets without seeking advice from the G.P or Pharmacist. Any advice given should be recorded.

Medication Refusal

When a young person refuses to take their medicine, then the G.P. should be contacted for advice. This information must be recorded and followed. Young people cannot be forced to take their medicines.

If a Young Person is Absent when the Medicine is Due

When a young person is absent and their medication is due, this should be recorded. When the young person returns, then staff must consider the time delay and seek advice if required from the Pharmacist, the G.P or NHS Choices website (as appropriate depending on the time of day). To miss taking a medicine completely can be dangerous depending on the medical condition.

Refusal of medicines

It is an individual’s right to refuse medicines. The home’s care staff will record the reason for refusal of the dose so that this can be appropriately discussed at the time of a medication review with the general medical practitioner and/or the pharmacist. More urgent cases will be reviewed immediately. When a child is considered incapable of giving consent to treatment, or where the wishes of a mentally incapacitated child appear contrary to the interests of that person, the general medical practitioner responsible for treatment will be consulted.

He/she should consult people with parental responsibility/carers and other members of the multidisciplinary team on any action to be taken. There may be certain circumstances in which covert administration may need to be considered to prevent a child missing out on essential treatment. A multi-professional team that includes people with parental responsibility, carers and relatives of the child must undertake the decision. Any decision must be reached after assessing the care needs of the individual child and written conformation of best interest decision for covert medication recorded in the placement plan for the child, with a date for reviewing the decision. 

Day Care - treatment outside the home

Steps will be taken by the home to ensure the continuity of supply of medicines to a child where that person spends time in two or more places e.g. outside the home in school or with relatives. Where a child goes out of a home regularly (e.g. is absent every or most lunchtimes) and requires medication whilst away from the home, the pharmacist and/or the child’s general medical practitioner should be asked to assess whether an alternative preparation is available which would avoid the need for a lunchtime dose. If it is established that the medicine must be taken whilst the child is absent from the home, a separate container of medicine should be requested by liaising with the pharmacist /general medical practitioner as appropriate. All medication leaving the home or being returned will be signed in and out as appropriate. 

Medicine check

The MAR chart identifies the medication to be given, its strength, dosage, frequency and timing. The staff member administering the medicine is required to check:

1. That the medicine has not already been administered to the child;
2. That the MAR chart and the pharmacy label match;
3. That the name of the child, name of medicine, strength, and number of dose units and frequency match.

If there is a discrepancy a check should be made with the pharmacy or person in charge before giving the medicine to the child.

MAR chart

The MAR chart will identify all prescribed medicines and will also be used to record other medicines administered e.g. non-prescription medicines. The persons administering the medicine and the witness will initial all medicine administered including PRN medicines. This is to facilitate audits at a later date and to ensure that the records are clear. It is essential that the person who administers the medicine refers to the record chart at the time of administration, and signs immediately the medicine has been administered. The recording of self-administration is not anticipated although the MAR chart will contain information about the date that a supply of medicines was given to the child.

Irregular, or “as required/needed” medicines (PRN)

Where medication is requested, but is not part of the child’s regular routine, then reference must be made to the plan of care. This must be updated if there is no current reference to the problem, and advice from the GP is likely to be necessary. Administration of PRN medicines is to follow directions as per prescription and guidance from prescribing practitioner. 

Lone Working

On occasions staff may be required to work on their own for a period of time. It may be the case that the administration of a medicine will have to happen during this period. Staff should ensure that they double check for themselves and make a record of any medical administration required during the period of time for when they were lone working.

This can be a problem when administering Controlled Drugs. It is important that the young person receives their medicine at the correct time therefore the member of staff administering the medicine, must also record that they were lone working in the register. It is not acceptable for another staff member to sign the register when they come in. You cannot be a witness to something you have not seen happen.

Spilled Medicines

When a medicine has been dropped on the floor or spilled then this must be safely disposed of and a note must be made in the records. A second dose should be offered to the young person (where a medication has spilled, leaving the remainder short for the completion of the course of the prescription, advice should be sought from the G.P as to how to make-up for the lost dosage).

When medicine has been spat out then this medication must be cleared away following the correct procedures and a note made in the records. However a second dose must not be offered, as staff will not know how much has been absorbed. If this persists the G.P should be contacted.

Detached or Illegible labels

If a label becomes detached from a container or is illegible, then staff must seek advice from the Pharmacist. Until this advice is received then the container should not be used.

Secondary Dispensing

Staff must ensure that medicines stay in the containers supplied and labelled by the Pharmacist. Medicines must not be placed in daily or weekly medicine trays.

Medication Errors Policy

In the event of an error being made in the administration of any medication, advice must be sought from the young person's G.P. or another medical practitioner/ help line (e.g. NHS Choices) immediately or as soon as the error has been discovered. Staff must record the advice that they have been given.

The home will endeavour to ensure, by way of the implementation and maintenance of sound procedures, that errors in the administration of medicines in the home do not occur.

The home accepts, however, that although a 100% error-free record must be the aim, mistakes may occur. The home strives to ensure that an open culture is maintained at all times (and staff report errors, or potential errors on every occasion), that proper investigation takes place, and any defects in procedure are identified and corrected without delay so as to reduce the potential for errors in the future.

Procedure

What counts as an Error? An error occurs when a child:

1. Is prescribed the wrong drug by the Medical Practitioner (e.g. GP); or
2. Is prescribed a drug, and it is not administered;
3. Is prescribed a drug, but is administered the wrong one, or the wrong dose, at the wrong date/time, or via the wrong route;
4. Is dispensed the wrong drug by a pharmacist: or
5. Self-administers, but takes the wrong dose; or
6. Self-administers, but has been given the wrong drug; or
7. Is administered the wrong dose by care staff in the home; or
8. Is administered the correct drug by care staff, but there is a failure to record the date/time/dosage and signature; or
9. Is administered the wrong drug by care staff; or
10. Has an adverse reaction to a prescribed drug; or
11. Has an adverse reaction following ingestion of a homely medicine; or
12. Is administered a drug/or self-administers, in any other circumstances which are in error, and/or against advice or instruction.

Clearly not all of the “errors” are attributable to the care staff of the home, although where any of the above errors come to light, then those responsible, or those who might be responsible, professionally, (e.g. Medical Practitioner’s, pharmacists) will be informed by the Manager of the home, so that corrective appropriate action can be considered.

Handling Errors – the general principles

Where an error occurs, and the error is attributable (clearly, or prima facie, or suspected) to a member of the home’s care staff then the incident will be handled in accordance with the following principles:

1. A detailed investigation will be conducted, and overseen, where possible by a responsible person not connected with the incident;
2. The investigation will be “informal” (in the first instance) in order to quickly get to the nub of the matter/problem;
3. The investigation will include everyone associated with the “incident”;
4. All relevant information arising out of the investigation etc. will be recorded;
5. The overriding concern is to ensure that the error is not repeated;
6. Lessons learned will be communicated to all involved;
7. Where education, training or counselling are advised, there will be no delay in implementation.

All staff are required to maintain a vigilant attitude towards the administration of medicines generally, within the home, and to report any circumstances where an error has, or appears to have, been made, or circumstances where an error might have been made, but for good fortune. These incidents are regarded as “near-misses”, and should be investigated in every case, as if they were real incidents.

Handling an incident

Incidents must be reported without delay, to either the Manager, the Assistant Manager of the home, or person in charge of the home (Senior Care Staff) at the time. The manager, Assistant Manager or Senior Career, will immediately take steps in order to ensure that any medical assistance, if necessary, is called immediately, and will put in place other measures, reflecting the nature, seriousness and immediacy of the incident. Such measures may include:

1. Advising Medical Practitioners, pharmacists etc.;
2. Advising parents, social workers etc., as necessary, and as appropriate to the young person; C. Making the situation “safe”.

The individual receiving the oral report will ensure that a written incident report is completed and filed.

Follow up

If, in the opinion of the Manager of the home, a member or members of the care staff are at fault, then that individual or individuals will receive:

1. Either a written note, (a copy of which is also placed on their file) recording the incident, with information as to how their fault contribution was assessed and identified, and what remedial action, if any, was to be taken as a result of the incident. (Applies generally to errors which should not be repeated, but where the consequences were not, and would not have been, dangerous); or
2. A formal letter of invitation to a disciplinary hearing, where the matter will be discussed and appropriate action taken within the framework of the home’s disciplinary process. Disciplinary action will generally be taken, in cases, for example, where a serious error has occurred (or might have occurred but for good fortune), or where there is repetition of previous mistakes (e.g. repeated failure to complete medicine administration records), or in circumstances where, in the opinion of the Manager of the home, disciplinary action is justified, having regard to the circumstances of the case.

If fault is a result of inadequate procedures then the Manager of the home will circulate all staff with a clear message as to what happened, the identification and implementation of new procedures, etc.

Verbal Alterations

There may be times when it is necessary to stop or change the dose of a young person's medication without receiving a new prescription. Verbal requests to change medication by the G.P. must be confirmed in writing before any changes are permitted. These changes must be recorded on all relevant medication records including the Individual Medication Record in the young person's file. Staff must note the change, the name of the Doctor, the time the confirmation of alteration was received and the date. Staff must not alter the dispensing labels. A note may be added saying 'Refer to record for new instructions'. Staff should check the next prescription to make sure these new changes have been implemented.

Adverse Drug Reaction

Any adverse drug reaction or suspected adverse drug reaction should be reported to the G.P before further administration is considered. Advice should be sought on whether the medicine should be stopped or the treatment carries on. Staff must record the advice that they have been given indicating the date and time and authorising Practitioner.

Drug Recalls

When a Drug Recall Notification is received then staff should check the medication to see if the Home is holding any stock. If there is none in stock then the notification should be signed, dated and filed for reference.

When stock if found that is listed on the drug recall, then staff must follow the directions given after isolating the stock.

See also Lone Working.

If a child spends time away from the Home, either on home visits, holidays or time spent at school, any medication due to be taken must be kept in the original labelled container.

Any medication taken away from the Home should be appropriately recorded on the individual child's Medication Administration Record (MAR), showing what medication has been taken away/handed over to parents/ carers. The person receiving the medication should countersign the record.

If the parent/ carers wishes, a copy of the MAR should be handed over to them, so that a record of administration can be kept; this may be handed back to the Home when the child returns.

If the person who is responsible for the child is a member of staff, then they must complete the documents for administration while they are away as normal.

The medication should always be handed over to someone responsible for the child.

This applies to specialist or skilled healthcare tasks, for example:

• For diabetic children;
• Physiotherapy programme;
• For the use of Buccal Midalozam;
• For the use of Rectal Diazepam.

If a child requires a skilled health task to be undertaken, this will only be carried out by trained staff, with the written authorisation of the prescribing Doctor in relation to the child concerned, and as set out in a Placement Plan or other written Health Care Plan.

Appropriate training will be provided, together with written guidance, as to how the skilled tasks will be performed and recorded.

If an overdose is suspected, hospital treatment should be sought without delay. Staff should try to find out what the child/young person has taken and if possible take a sample to give to a medical practitioner.

Possible signs of an overdose:

• Mild nausea/vomiting;
• Paler skin;
• Blue lips or fingernails;
• Not waking up or reacting to a loud noise;
• Shallow or disrupted breathing;
• Gurgling, snorting or snoring/choking sounds;
• Slow or very faint pulse.

It can take a long time between taking the substance and the first signs of an overdose; children/young people may verbally 'boast' about having taken an overdose: even when there are no signs, but staff must consider that there is a chance an overdose has been taken and they must act in caution and seek medical attention.

What to do if someone is reacting to an overdose

• Lie them on the floor;
• Put them in the recovery position;
• Call the ambulance - 999 - inform the operator of the overdose;
• Do not leave the child/young person alone, make sure they don't roll onto their back;
• Inform the ambulance team what the person has taken; try to gather all the packaging you can find;
• Get some help, keep other children and young people away (but don't dismiss any valuable information that they may be trying to pass on to you).

DON'T

• Walk the child/young person around;
• Put the child/young person in a cold bath/layer them up to heavily to generate warmth;
• Give them a drink.

Recording and Review

See also: Self-Harming and Suicidal Behaviour Procedure.

Legislation, Statutory Guidance and Government Non-Statutory Guidance

Promoting the Health and Well-being of Looked-after Children

Good Practice Guidance

Managing Medicines in Care Homes NICE Guidelines

Useful Websites

Health and Safety Executive Website

CQC information on Controlled Drugs