2.18 Medication Procedure for Short Break Homes

1. Introduction

This procedure sets out the procedure and process for the Administering and Dispensing of Medication for Short Breaks.

Consent Forms And Medication Administration Record (MAR) Sheets

Medication required to be administered to a young person whilst accessing short breaks should have been clearly identified through the care planning process. This includes consent forms having been completed and signed in preparation for the young person's first visit to the Home. Prior to this first visit, the MAR sheet will be prepared, using the consent form and care plan as a guide. The MAR sheet requires two staff to complete, the second member of staff checking the information recorded as being correct, countersigning as indicated.

Throughout the young person's subsequent journey through the short breaks service, any changes to the medication or information regarding the medication, is to be recorded on the front of the MAR sheet.

Where a medication is changed, for example a dose is increased, a new consent is to be completed and signed by the parent. Frequent changes may require the completion of a new MAR sheet or an additional MAR sheet where numerous medications need to be added.

2. Administering and Dispensing Medication

Medication is everyone's responsibility and all staff have a duty of care to ensure all young people's health care needs are promoted and safeguarded. The following procedure in managing medication must be adhered to at all times.

A senior member of staff (Designated shift leader /RCO2 or above) must take the responsibility for all decisions relating to young peoples' medication.

The senior member of staff must plan this task to ensure that medication is drawn up and given in a safe way.

One person to dispense and administer any prescribed medication to a young person except as follows:

Where identified in Care Plan / risk assessment;
Where there are capability concerns;
Where a person does not feel confident to complete the process alone;
Where a member of staff is being supervised by a senior as part of their induction.

Wash hands before dispensing medication. Utmost care is to be taken to reduce contact with medication via handling. If such contact cannot be avoided, gloves should be worn or a drug triangle used.

Never leave the medication room or medication cupboard unlocked or unattended.

Focus only on medication – do not answer the phone, be involved in other conversations etc.

Checking involves 'marrying up' instructions on the MAR sheet against the instructions on the prescription label on the medication, with the correct young person. Staff are to confirm that the medication they are drawing up matches the instructions on the MAR sheet, consent form and prescription label.

Before administering medication; check the MAR to determine the time that the last dose was given and ensure that there is sufficient time between doses, check that the medication has not already been given.

Medication is only ever drawn up for one young person at a time. Staff are to sign the MAR sheet once the medication is drawn up/dispensed.

Medication must not be drawn up in advance and left in the medicine cupboard or trolley.

Medication can only be drawn up in advance when a child is being taken out and medication will be required whilst away from the Home. This must be recorded on the outing risk assessment and on the MAR sheet as if it were being given in the Home.

The medication is then immediately given to the young person by staff, informing the young person by their preferred method of communication. Staff are to sign the MAR again on completion of administration recording the exact time that the medication was given.

IMPORTANT: Medication is never to be administered to a child by anyone other than the member of staff who dispensed it.

If the young person refuses to take the medication once dispensed, it must be disposed of. A refusal must be recorded on the MAR sheet over the staff initials as a refusal (red 'R'). All effort should be made to encourage the child to take their medication, employing such strategies as allowing a period of time for the child to calm or taking them to another room.

When a refusal occurs, or a child has spat out the medication and staff cannot be certain of the amount taken, medical advice should be sought from the young person's GP or a pharmacist and parents must be informed as soon as possible. Where medical advice is given that a further dose should not be given, this must be adhered to. Where a parent requests that another dose is given, the medical advice should be reiterated to parents and no further dose given.

Disposal of any medication which has been spat out, dispensed but refused, is out of date, is discontinued or recalled, or has been dropped, is essential. The discarded medication must be put into an envelope clearly labelled 'For return to Pharmacy'. This is then put into the medication cupboard along with the Disposal form and taken to the pharmacy. The pharmacist must sign the disposal form when the medication is handed over and the form returned to the Home.

3. Controlled Drugs Procedure

Controlled drugs are prescription medicines controlled under the Misuse of Drugs legislation. Such drugs include Concerta and Ritalin. These drugs are subject to stricter controls than regular prescribed medicines.

Staff are required to record, dispense and administer controlled drugs.

Controlled Drugs must be stored in the separate lockable section within the medicine cupboard.

We are required by law to keep a separate register of all the records relating to controlled drugs. Records are made in a hard bound book 'Controlled Drug Recording Book'. This book is kept in the controlled drug section in the medicine cupboard. Two staff must counter sign all records within the Controlled Drug Recording Book. The book provides an audit trail and accounts for the movement of every single Controlled Drug tablet.

The first pages in the Controlled Drug Recording Book are an index. The page number relates to the page further in the book which contains detailed records relating to the receipt and administration of the controlled drug. When the page is completed, a new page is started, and that page number is put in the index.

Every time a Controlled Drug is given, the stock must be counted by both staff to make sure that the actual amount is the same as that shown as balance in stock in the record book. It must be counted before the medication is dispensed. The tablet counting tray is in the controlled drugs section in the medicine cabinet.

If there is any discrepancy it must be rechecked. If there is still a discrepancy the senior on shift must be informed immediately and the on call person informed.

4. Timing of Medication

The prescription label, Patient Information leaflet, direct instructions from a health professional and a child's parent/carer will indicate the appropriate times at which medication is to be administered. This should be recorded on the MAR and Medication Consent form.

Where an exact time is not specified, medication will be administered at a time that suits the routines of the young person and the Home.

The Institute of Safe Medical Practices advises on Timely Administration of Scheduled Medication. The definitions are:

Scheduled medications – where maintenance doses are administered according to a standard, repeated cycle of frequency;
Time-critical medications – these are a limited number of drugs where delayed or early administration of more than 30 minutes may cause harm or sub-therapeutic effect, Includes but not limited to: Medications with a dosing schedule more frequent than every 4 hours. These medications are to be administered at the exact time indicated when necessary (e.g. rapid-acting insulin), otherwise, within 30 minutes before or after the scheduled time;
Non time critical medications – these are:
- Medications prescribed more frequently than daily, but no more frequently than every 4Hours; when they should be administered Within 1 hour before or after the scheduled time;
- Daily, weekly, monthly medications which should be administered within 2 hours before or after the scheduled time.

The time at which a medication is administered must therefore be recorded on the MAR sheet on every occasion.

5. Pro re nata (PRN) Medication

PRN (Pro re nata) is a Latin phrase meaning 'as the need arises'. Therefore medication which is PRN, which may be prescribed, is not taken regularly, but only given as and when needed. It is usually prescribed to treat short term or intermittent medical conditions.

Any PRN medication is recorded on the back of the MAR sheet and is booked in, dispensed and administered in the same way as regular prescribed medication.

The MAR sheet must be checked to ascertain when the last dose was given, before dispensing and administering a further dose.

6. Covert Administration

Covert administration is when medication is given in a disguised form without the knowledge or consent of the person receiving it. This may be because the young person does not have the capacity to understand the consequences to their health and wellbeing were they to refuse it.

Examples of covert administration are such as crushing a tablet into a drink or mixing it with food. The exact form of covert administration needs to be specified as, for example, the action of crushing a tablet may affect the release time of the medication.

The decision to administer altered medication – for example crushed or diluted – covertly, will be a multi-disciplinary one involving the parent/carer and a health professional as a minimum. The decision should be recorded in the child's Care Plan, supported by a letter of agreement from a medical practitioner, stating why the decision has been made and how the medication is to be administered.

It is acceptable practice to put unaltered medication into food, such as yoghurt, at parent's request, without medical agreement, where this aids the taking of the medication. Written parental consent is required, including the method of administration.

7. Management of Medication Discrepancies and Errors

Definitions

Discrepancy: A medication discrepancy is an incident where there is a conflict of information present. Examples of discrepancies are not exhaustive but include:

Tablets/medication in wrong container;
Label on bottle/container indicates medication of out of date;
Dosage differs from MAR sheet/Consent form;
New medication sent in but not listed on MAR sheet;
New medication sent in but no consent form;
Medication is for wrong Child/Young Person;
Insufficient medication sent in.

Error: A medication error is an incident where there has been an error in the PROCESS of prescribing, dispensing, preparing, administering, monitoring or providing medical advice, regardless of whether any harm occurred. Examples of errors are:

Miscount of tablets;
Medication not signed for on MAR sheet;
A prescribed dose is not given;
The wrong dose is administered – including the administration of an extra dose;
Administering a medication to the wrong young person;
Wrong dose interval;
Incorrect administration route;
Not following warning advice e.g. Take with food;
Administration of a medication to which the resident has a known allergy;
Administration of a drug past its expiry date.

All errors are to be recorded on incident forms.

Fitness of staff undertaking medication

Staff are ultimately accountable for their health and well-being. If however a staff member is concerned that their current health and well-being may impact on their performance and/or decision making, they must take immediate action and at the earliest opportunity report this to a senior member of staff. Following discussion, agreed actions will be taken that will safeguard and protect those young people with whom we have a duty of care to.

Responsibilities of the Shift Leader

The Shift Leader has the overall responsibility for ensuring that those undertaking any part of the medication are both confident and competent in Safe Handling of Medication.

The Shift Leader must also identify at shift handover team members who are responsible for medication.

The Shift Leader must undertake a check of each child's Medication Administration Record (MAR) at the end of the shift to ensure all medication has been taken and sign the shift plan when completed.

Responding To A Medication Error

IF AT ANY POINT IN THE INCIDENT YOU ARE CONCERNED FOR THE HEALTH OF THE CHILD DIAL 999 IMMEDIATELY

If a medication error occurs, the following action must be taken:

Shift leader to ensure that all staff are aware and instruct one member of staff to closely monitor the child for any changes to their usual state of health and to report any changes to shift leader;
Shift leader gathers all the relevant information regarding the child as follows:
- List of medication;
- What the medication is for;
- MAR;
- Child's details i.e. the file front sheet.
Commence a detailed report on an Incident form (AIR) and specify all actions taken and by whom i.e. all telephone calls;
Shift leader to immediately seek medical advice from the child's GP. Where the incident has occurred out of hours a recorded message will give a contact number for the out of hours GP service which should then be contacted. If this service is not available immediately then ring a Pharmacist, 111 or A&E, depending on the severity of the incident;
Where possible the telephone should be switched to loud speaker and an additional member of staff present for concurrence of the information/ advice given, some of which may be complex and detailed;
Record the key points of advice given and request where possible that this be confirmed in writing via fax / email form the medical practitioner giving the advice. The information can then be relayed to the carers;
Contact child's parents/ carers as soon as possible to advise of the incident and the advice by the medical practitioner. Parents/ carers to be kept informed of any changes;
Contact the on call manager to inform them of the error and actions taken. Shift leader and on call manager to determine any further actions to be taken in the light of the medical advice given e.g. frequency of observation, signs and symptoms of deterioration;
Complete an accident form (PO3);
Inform the child's social worker as soon as possible, or by the next day working day.

If a child is admitted to hospital following a medication error:

Notify the parents/ carers and on call manager;
Where possible, staff member to accompany the child to hospital;
Information to be taken with the child: MAR sheet, consent form, child's details, all medication that the child is taking;
Continue with Incident Form;
Consider if it needs to be reported under RIDDOR;
Prepare a draft Schedule 5 Notification (see The Children's Homes Regulations 2001) and email to Homes/Assistant Manager;
Notify Ofsted, quoting the home's registration number on the next working day;
Homes/Assistant manager to complete Schedule 5 Notification and send to Ofsted (see Notification of Events/Incidents at Children's Social Care Providers);
Inform LCC Health and Safety team via online recording system (BS task);
Inform child's social worker;
In either event, it is advisable for the staff involved in the error occurring, not to administer any further medication until otherwise instructed by the Homes Manger or Senior Manager.

Management Action:

In the event of a serious medication error the Homes Manager/Assistant Manager will:

Review the records and statements made by those staff involved in error and identify key factors that potentially contributed to the error occurring.

Debrief with those staff involved in the medication error to discuss:

The error;
To seek further information or clarification;
Identify any potential learning outcomes;
Identify any potential changes required to procedure or practice.

Manager/Assistant Manager will inform and discuss with the relevant Head of Service (HoS) the details of the incident/error and agree the course of action to be taken.

Recommendations made following a medication error will be disseminated as follows:

Team Meetings;
Where appropriate be shared accordingly with the wider Residential Service;
Where appropriate request that amendments be made to current Policy and Procedure.

Medication errors and learning outcomes will be discussed and recorded within the employee's supervision record.

If there is evidence to indicate that there are concerns in respect of capability an employee will be subject to:

LCC Capability Policy and Procedure.

Or in cases of misconduct:

LCC Disciplinary Policy and Procedure.

The circumstances and seriousness of a particular case misconduct as outlined within the Council's policy may be regarded as gross misconduct. Except in the most exceptional circumstances gross misconduct will result in summary dismissal, without notice.

Outcome For Parents

The Homes Manager/Assistant Manager to make telephone contact at the earliest opportunity with the child's parent to discuss the error, offer an apology and if possible an explanation and reassurance. The Manager will inform and agree with the parent of the actions that will be taken and confirm with them that they will be informed in writing of the findings. The Manager will inform the child's parent of their right to make a formal complaint and be provided with the details of how to make a complaint.

8. Discharge of Medication

Where medication is required for a child during a trip out, the medication taken should be recorded on the outing risk assessment.

The dispensing and administration of the medication must be recorded on the MAR sheet as if it were being given in the Home.

When a young person is discharged from the Home, the Medication Received and Returned form should be completed with the amount of medication returned to the parent/carer. If at this point an error is identified, a double check of calculations and counting of medication should be undertaken. Where a miscount cannot be confirmed, the Medication Error procedure will be implemented, see Section 7, Management Of Medication Discrepancies And Errors.

9. Homely Remedies

Homely remedies are those which can be purchased from a retail outlet i.e. are not prescribed or overseen by a pharmacist.

Where a young person regularly uses homely remedies, a consent form should be signed by the parent/carer.

Homely remedies brought in must be recorded on the Medication Received and Returned form and the MAR sheet, along with prescribed medication.

Before administering a homely remedy, the parent/carer must be consulted. A check must be made that the remedy is compatible with the young person's prescribed medication. The Patient Information Leaflet should indicate compatibility.

The homely remedy is administered in line with the prescribed medication procedure.

It is acceptable for homely remedies to be kept in the medication cupboard for general use. However, the only types to be retained are those which are Paracetamol based. A variety may be kept according to the ages and needs of the children who access the short break service.

Any homely remedies kept on site must be regularly checked for expiry date and a record kept of when and to whom it has been administered. Homely remedies must be disposed of in the same manner as prescribed medication.

10. Medication Forms to be used in Short Break Homes

All relevant forms to be used in Short Break Homes can be located on Lincolnshire County Council's Intranet – George, under Children's Services Core Forms K – M and are as follows:

Medication Administration Record;
Medication Consent Form - PRN;
Medication Consent Form - Regular;
Medication Discrepancy Form;
Medication Disposal Record;
Medication Handover Record;
Medication Homely Remedies;
Medication Received and Returned Record.

Appendix 1: Medication Process for Short Break Homes – Flowchart