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LO1 Understand how the design and review of services promotes and maximises the rights of users of health and social care services
1.1 explain how current legislation and sector skills standards influence organisational policies and practices for promoting and maximising the rights of users of health and social care services
1.2 analyse factors that may affect the achievement of promoting and maximising the rights of users of health and social care services
1.3 analyse how communication between care workers and individuals contribute to promoting and maximising the rights of users of health and social care services
Tuitt, 2010 describes power as the capacity to affect the behaviour of another – to persuade another to do something that he would not do on his own. In practice with adults at risk, especially where there are issues surrounding mental capacity , it is vital to remember that individuals can easily be disempowered by the opinions and views of other people.
To understand how empowerment is achieved, it is critical to look at the elements of power which can be instrumental in both promoting and hindering independence and autonomy. Veneklasen and Miller (2002) focused particularly on 4 power dynamics which are utilised during interactions with people.
- Power over – one of the most commonly recognised forms. This type has negative connotations and can be applied to oppression, coercion, discrimination and abuse. This damaging action can disempower individuals and wider communities.
- Power with – can be associated with partnership working, and the ideology that there is collective strength in numbers based on mutual support and collaboration. Power With, has the potential to stop discrimination, stereotyping, social conflict and to promote equality
- Power to – relates to the individual potential of each person to realise their goal. With appropriate support provided by following a person-centred model, it opens up possibilities for users of services to be more independent and to have control over their own lives.
- Power within – represents the capacity to acknowledge unique differences, such as culture, values and interests and to respect them.
White et al (2003) considered “empowerment to be the main factor in safeguarding adults in care homes and residential settings from abuse and exploitation”. Practices which promote problem solving such as joint-working, educating, personalisation and person centred planning should be a key ethos in agencies that provide care and support. This places control and ownership of all decisions into the hands of the individual resulting in less scope for abuse to occur.
- Empowerment is achieved by identifying that all individuals have the right to be in control of their own lives, and by recognising that power, although it may pose a risk, is key in promoting autonomy. An organisation that considers empowerment of its clients as the root of good care delivery, is able to adapt sensitively to the needs of individuals and their carers.
- Willingness to work towards solutions – For individuals with learning disabilities there are frequently barriers to achieving chosen outcomes which usually stem from inequality or poor communication. Working to resolve these issues demonstrates consistency of values and the ability to promote change.
- Client led – person centred, creating support plans with the individuals rather than for them. Listening to family members and the client about their preferences, promoting the continuation of prior interests.
- Recognition that power differentials exist- Traditionally powerful groups of people in society such as social workers, government officials and the medical profession are the ones who have defined disability and who have made critical decisions concerning how the needs of vulnerable adults should be met (Lordan, 2000). The effect of this can be seen in those individuals who “Don’t want to bother the doctor” or believe that the chief agenda of social workers is to remove children or put adults at risk into institutions. This is a theory which has its roots in a historical perspective, which was, at one point, a very real feature of how the care system worked and how those with learning disabilities were viewed. If managers and staff are already starting from a perspective which acknowledges this viewpoint, it can support in making the individual feel understood and accepted.
- Effectively working in partnership with other professionals but sharing a common goal – this should be demonstrated by shared power, distribution of key information and consideration of all client pathways. The Department of Health’s “Valuing People Now” command paper in 2001 explicitly focused on those with learning disabilities, and defined to the government how to improve facilities by distributing guidance to all learning disability partnership boards. Within Objective 11 The Department of Health emphasised that agencies should be working together in collaboration to provide a holistic services for individuals.
As an organisation we should incorporate an ethos that empowers both the individuals using our services, and the employees. One of the ways in which this can be delivered is by embedding a realistic and honest mission statement. The current statement highlights the challenges, such as discrimination, isolation, and a lack of inclusion that people with learning disabilities are still facing and how the organisation works “alongside” users of services rather than “on behalf of them”.
This links to various pieces of legislation
- The Equality Act 2010 – which classifies disability as a protected characteristic and makes it unlawful to discriminate against an individual either directly or indirectly based on their condition (legislation.gov.uk, 2010).
- The Human Rights Act 1998 – Article 14 – the European Court of Human Rights has recently held that Article 14 covers disabilities and various health conditions, within the words “or other status“ (legislation.gov.uk, 1998).
- The Care Act 2014, which puts the onus onto local authorities and agencies providing care to be proactive and prevent needs arising (Department of Health, 2014).
- The Health and Social Care Act 2012 which promotes collaboration and describes how authorities along with associate commissioning groups must contemplate the extent to which needs could be more effectively met (legislation.gov.uk, 2012).
The mission statement also allows individuals to form an idea about the type of values an organisation is promoting, and can support in making an informed choice about whether the agency is suitable for them. By having a testimonial which echoes legal aspects, clients can see that their rights will be promoted.
The organisation must consider inclusive recruitment to be essential and increase the number of employees with a learning disability. Following the inclusive recruitment policy and procedure means that shortlisting, interviews and any other selection procedure will be carried out without regard to disability, age, gender or sexual orientation. The organisation or agency must acknowledge that individuals are more likely to be satisified in their job role and contribute positively to the organisation if the recruitement process is inclusive. This is echoed by a Skills For Care report which highlighted the particular benefits that organisations associate with hiring people with disabilities. Included were:
- improved services – disabled workers can apply personal experience and insight to services
- Personal qualities – employers realised that reviewing working conditions could enable individuals to develop qualities and skills that were valuable to the workplace
- Cultural change – The demonstration of value based effective employment models can support in promoting cultural change
- Improved public perceptions – The organisation is seen as being inclusive and this can lead to an increase in custom and an enhanced reputation.
- Reinforced work teams – more diversity within the team can further develop understanding of learning disability (Skills for Care, undated).
Promoting Positive Risk Taking
Accepting that risk taking is a natural part of everyday life is key to providing inclusive support and ensuring that people are not just cared for, but are happy. It is also vital in ensuring that clients get to apply the skills they have and don’t lose them through lack of use. Balance is a critical consideration in the promotion of responsible decision making. “Reasonable risk is about striking a balance in empowering people who use services to make choices, ensuring that the person has all the information, tailored to their specific needs, in the appropriate form, to make their best decisions” (Department of Health, 2007).
One example of positive risk taking for an anonymous gentleman S, in his 30’s with a moderate learning disability, and who receives 40 hours a week care and support. An outcome he wanted to achieve was to be able to go on holiday alone. His chosen destination was Bournemouth, full board in a hotel. This risk was managed by:
- looking at the impact of him achieving this – independence, autonomy, personal choice, inclusion.
Versus the impact of him not achieving this:
- dependence on others, restricted opportunities, social isolation, and exclusion from the things others take for granted.
Possible hazards of the holiday such as getting lost, forgetting to take medication, losing money and abuse were identified as moderate risks, but by supporting S to access information via email, phone calls and in travel agents, he was able to find a hotel which catered specifically to those with moderate learning difficulties with staff who were care workers. In collaborating with the hotel we were able to establish a care package that enabled S to go out independently while on holiday within the immediate area, and still have support from care workers at the hotel when needed. Any barriers to him participating in what he wanted to achieve had now been removed and this resulted in S feeling empowered, in control of his own life, and happy that he had accomplished an outcome he had really wanted.
Knowledge of laws (legislation) and regulations
It is critical that employers and staff have knowledge of the laws and guidelines which is in place to enhance the health and well-being of clients. Care agencies incorporate local strategies which are drawn from legislation and are used to provide correct practice and method in accordance with legal requirements.
The support planning ,and health and well-being policies and procedures both have links to the Care-Act 2014 and the Equality Act 2010 and are rooted in providing a person centred and individualised support plan while still meeting contractual and regulatory requirements. The focus is always on the person recieving care and support, their abilities and autonomy. Documentation like this will always take into consideration:
- Health conditions an how they can be better managed
- The sensory needs of the individual
- Religious and cultural needs
- Educational and employment opportunities
- How the client likes to socialise and where
- Who is important to them
These local strategies are all in place to protect, empower, both employees and service users. Adhering to these systems ensures that a best practice approach is able to be applied. The Care Quality Commission are the independent regulator of health and social care in England and responsible for overseeing practice in all care organisations who provide care and support. They inspect, monitor and ensure standards are being observed. To determine compliance they do on the spot unannounced checks on services and also publish poor ratings on their website (The Care Quality Comission, 2017). This promotes company accountability and acts as a monitor to the public about the kind of agency they may be contemplating using.
Confidential information relating to users of the organisation is safeguarded by the Data Protection Act 1998. Sensitive data is defined as personal data comprising of information as to the cultural or ethnic origin of the data subject, his political or religious beliefs and other beliefs of a similar nature, his sexual life, his physical or mental health or condition (Data Protection Act 1998).
In order to holistically meet the needs of clients, care staff demonstrate sector skills as outlined in The Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England (2013) which details that “care workers should promote and uphold the privacy, dignity, rights, health and well-being of people who use health and care services and their carer’s at all times” (Skills for Health & Skills for Care, 2013).
One of the biggest issues that organisations face is staff sickness. Occupations reporting the highest rates of total cases of work-related stress (three-year average) were health professionals (in particular nurses), teaching and educational professionals, and caring personal services (in particular welfare and housing associate professionals); The NHS 2012 Staff Survey results showed correlation between problems experienced by staff and the causes of stress as reported in the LFS:
- under a third of staff (30%) feel that there are enough staff to enable them to do their jobs properly;
- one third are not satisfied with the support they get from their immediate manager;
- a quarter reported they had experienced bullying, harassment or abuse from either their line manager or other colleagues;
- only one third felt that communication between managers and staff is effective (Kline, 2013).
With social care in crisis and with limited funds and low pay how can this be remedied? The short answer is it cannot. It can only be managed. Regular supervision is one way to ensure staff are coping with the stresses of their role, as is having positive relationships with colleagues and an open door policy with management. Many organisations empower their staff base by offering confidential counselling and health services free of charge. This gives employees an opportunity to speak to an independent professional. There is research to suggest that workplace stress may manifest due to “perceived distance between managers and practicing staff , and from managerial failure to demonstrate understanding of the pressures placed on staff. This can result in employees feeling that they are not valued” (Braye & Preston-Shoot, 1995). With illness comes staff shortage, and those who feel under-valued by their employers are less likely to want to cover extra shifts. An organisation with a positive culture could remedy this by being flexible with staff, understandin the pressures encountered, and encouraging members to speak to them about problems.
A lack of available resources can restrict good practice and generate an ineffective, drip-feeding approach to achieving outcomes for individuals. This can cause conflict between colleagues and in the client/carer relationship. If means are not available people can become disempowered. This can result in:
- Failure to work cohesively
- Power becoming unbalanced
- Inability to address known areas of concern due to resource limits.
- Loss of shared vision.
- Deterioration of the individuals health and well-being.
- Breakdown of communication
When this occurs the opportunity for incidents or unintentional abuse is broadened. “Conflict can be minimised by having clearly defined roles, and incorporating a reflective and open approach. Management should be skilled at managing processes of change and transition, as these are key times that conflict can happen” (Mantell & Scragg, 2009). In learning disability practice conflict can often take place through misunderstanding. Individuals with intellectual disability may not fully understand information that they are being given, and this can result in misinterpretation. Ensuring clients have access to information in accessible formats such as easy read documents or PECS symbols can reduce this, and at the same time promote their independence.
The importance of effective communication becomes especially important if the needs of a client change. People with learning disabilities have a shorter life expectancy and increased risk of early death when compared to the general population. The factors that people with learning disabilities face, especially people with less severe learning disabilities, means they are more likely to be exposed to common social determinants such as poverty, poor housing conditions, unemployment, social disconnectedness and overt discrimination (Baines & Emerson, 2010). There are also known links to higher death rates from hospital admissions in those with intellectual disabilities because of communication problems. To prevent deterioration when a clients health needs change, it is vital that care staff record information, and update and review documents which outline medications and support needs. There should be a strong focus on joint working relationships so that the individual is getting personalised health and social care from all professionals involved. A change in care needs may need that the individual will need to be re-assessed by the local authority. Being proactive and recognising and effectively communicating early changes in the client can prevent crisis management at a later stage. The importance of this should be promoted in staff meetings and spot inspections.
LO2 Understand how to promote the participation and independence of users of health and social care services
2.1 explain factors that may contribute to loss of independence, non-participation and social exclusion for vulnerable people
2.2 analyse how organisational systems and processes are managed to promote participation and independence of users of health and social care services
2.3 analyse the tensions that arise when balancing the rights of the individual to independence and choice against the care provider’s duty to protect
Understand how to promote the participation and independence of users of health and social care services
For individuals with learning disabilities there are frequently barriers to achieving chosen outcomes which usually stem from inequality or poor communication. An organisation providing care and support must have a willingness to work towards solutions. In the support of vulnerable adults, core practice should always focus on ways of support that empower. Promoting independent skills and decision making can instil a sense of power and control within the client that is often misplaced within the midst of multi-disciplinary meetings and assessments. There is also a vital need for those delivering care and support to understand why individuals may feel that control over their own life is restricted, and how this can impact upon behaviour, decisions, risk-taking and lifestyle choices. There may also be an uncertainty and unfamiliarity with care services or a misconception that agencies are in a position of power and authority on which the individual is totally dependent. Adherence to policy, risk promotion and incorporating a best-practice ethos can limit the perception that services are in control and maximise autonomy and independence.
Mr G, who is 32 years of age and has autistic spectrum disorder with additional moderate learning disability lives independently at a service for individuals with learning disability and receives 24 hours of care a week from the organisation to:
- Maintain community presence
- Support with household tasks
- Receive support with shopping
- Maintain all aspects of his health
- Receive guidance with finances
- Receive support with banking and benefits
- Receive support with anxiety
The client’s anxiety and autism impact upon his ability to interact socially, and to effectively express himself well. This results in him repeatedly questioning people about things he already knows the answers to as well as shouting, crying and behaving unpredictably. This has previously compromised both his safety, and the safety of others. In addition to this, Mr G’s communication difficulties combined with anxiety have made it extremely difficult for him to identify health and wellbeing outcomes effectively. It has also made applying legislation and local policy problematic and has the potential to prevent the client from achieving outcomes and opportunities, therefore limiting inclusion and independence.
Individuals with disabilities face many challenges. When these are further complicated by a lack of resources with which to address problems, or by ethical dilemma, the individual is at risk of being disempowered. Examination of Mr G’s risk assessment highlights that environmental noise and lighting are significant triggers to his behaviour. In addition to this, anxiety was also present when unfamiliar staff members were on shift. The term challenging behaviour is often used as a description for conduct that is of such intensity, frequency, duration that the physical safety of the individual or others is placed into jeopardy or behaviour that is likely to seriously limit or delay access to or use of ordinary facilities (Emerson & Einfield, 2011). For Mr G, this is a barrier to achieving independence because the issue is rooted in sensory issues and dislike of routine which are attached to his autism. Research has shown that “unusual reactions to sensory stimuli are experienced by 90–95% of people with an autism spectrum condition” (Elwin, M., Schröder, A., Ek, L., & Kjellin, L., 2016). This is not unfamiliar within the client-group setting, but for Mr G the effect is such that his chosen outcomes are at risk of not being achieved. Client resistance to change may influence on aspects of the support plan being fully achieved and can result in moral dilemma whereby support staff must respect the wishes of the individual, but also recognise that rights are at risk of not being exercised. This has the potential to restrict independence by preventing ways of working which are more beneficial for the client being incorporated. Consequently, client autonomy is at risk of being compromised thus disempowering the individual.
The Statutory guidance for Local Authorities and NHS organisations to support implementation of the Adult Autism Strategy (2015), states that adults living in supported environments should have their sensory needs and differences recognised and be supported with this, and that support staff should recognise when a person with autism is experiencing stress and anxiety and make provision for this within their care. There is additional direction which advises that “health and care staff who are highly likely to support people with autism are appropriately trained beyond general basic awareness about autism” (Department of Health, 2015).
Current Organisational Systems and legislation
For those individuals with a learning disability who receive support in a health or social care setting, choice and independence can sometimes be disregarded. Support staff or even family members ma assume that the individual cannot distinguish what they want, and that because of their disability, the decisions they make are not logical. It may be felt that doing something autonomously is too big a risk, or misunderstanding within partnerships over who is responsible for being accountable for a decision. It is apparent now more than ever that there is a crucial requirement to work in in partnership alongside those with vulnerable adults and their families to safeguard from abuse and ensure maximum independence and inclusion.
There are various systems in place within the organisation to promote independence. Staff are required to work within the remit of local policy, codes of practice, duty of care and their own job role. There is a requirement to attend and upkeep learning and development which is relevant to the independence and support of individuals, as this enables staff to work successfully, and provides the crucial skills with which to achieve high quality delivery of care.
To increase the autonomy of an individual with learning disabilities, it is imperative that communication with them is sustained through their chosen method, and that the organisation is versatile and adaptable with support times as this maximises the potential of making independent decisions. Mr G’s right to make decisions and exercise independence is detailed in the Adult Autism Strategy Guidance which proposes to local authorities that “People should live in their own homes with support to live independently if that is the right model of care for them” (Department of Health, 2015) and in the Disability Discrimination Act (1995), which expresses “It is unlawful for a provider of services to discriminate against a disabled person in refusing to provide, or deliberately not providing, to the disabled person any service which he provides, or is prepared to provide, to members of the public”. Rights to independence choice and opinion are additionally promoted by the Human Rights Act 1998 within article 10 which states:
Everyone has the right to freedom of expression. This right shall include freedom to hold opinions and to receive and impart information and ideas without interference of public authority and regardless of frontiers”.
The Health and Wellbeing Policy
Person-centred planning and care is an expectation of the Care Act 2014 and is outlined within the local health and wellbeing strategy of the organisation. The policy identifies that wellbeing is not simply a single aspect, but is multifaceted and includes:
- How much autonomy a person has within their daily life
- Community presence and social inclusion
- Where they choose to live
- Educational/employment opportunities
- Mental wellbeing
- Peer and family relationships
There is additional focus on understanding how the past experiences of an individual can impact upon the outcomes they want to achieve, and the decisions they make.
Mr G’s requirement for care and support immediately places him at more risk of social exclusion and isolation than the rest of the general population. Applying guidance from the Health and Wellbeing policy into the risk assessment process ensures that hazards are minimised and that Mr G is able to continue accessing social activities in the community with minimised scope for incidents to occur. Communication is additionally promoted within the policy and this is applied within the risk assessment via consultation and discussion with Mr G and his family surrounding the dangers of being alone in the community. Discussion, reinforced with his chosen picture symbols ensures that he has a better understanding of the dangers that may present in the community, thus increasing his awareness and consequently the control he has over his own life.
The Equality and Diversity Policy
The Equality and Diversity policy is in place within the organisation to ensure individuals with learning disability are valued equally, listened to and included. In order to apply this philosophy, the organisation will:
- Listen to people with a learning disability
- Fight for the changes that people with a learning disability, and their families and supporters, want and need
- Support all people living with a learning disability in all parts of their lives
- Give excellent information and advice
- Work alongside individuals and groups who want the same things we do
The study titled “Our lives, our communities: Promoting independence and inclusion for people with learning difficulties” highlighted that the more choices that people with learning difficulties had, the more they were included in their local community. The more independently they lived, the more people they knew (Hart, Shane, Spencer, & Still, 2007). It is well documented that individuals who have less opportunity to maintain their community presence, are at higher risk of social isolation. In those with learning disabilities this often occurs due to being reliant upon carers in order to access activities in society, or due to lack of available finances. The equality and diversity policy supports the risk assessment for Mr G, and this is delivered within the document by the organisation putting measures into place to overcome the present barriers which are preventing him from accessing chosen leisure activities safely, and improved ways of communication.
Having accessible information is a crucial part of participation and independence as this supports the client in making well informed decisions. Individuals with intellectual disabilities, autism or sensory impairment depend on having information that is understandable and easy to access. The organisation provides accessible information about:
- The use of the complaints procedure
- Various government benefits
- Abuse, how it may present and what to do if it occurs
- Emergency contact numbers
- Social events, activity clubs
- How to use emergency equipment such as the fire extinguisher
- The procedure to follow in the event of a fire
Having available information provides Mr G with a system to exercise his independence, and limits his dependency upon others, therefore increasing his sense of power and control over his environment and life.
Conflict between rights and duty of care
Tension can arise within the care environment for numerous reasons. Employees may not always agree on the most suitable course of action in the support of an individual, and this can be a cause of inconsistent and fragmented care. Other stakeholders involved in the care of Mr G, such as multi-disciplinary team members, may have differing priorities to those outlined in the risk assessment and could feel that some aspects are unrealistic or not in the best interests of the client. Fears over safety can be a source of conflict, and have the potential to prevent the individual achieving independence. “Providers must make sure that choices are made by those with the legal authority or responsibility to do so, but they must work within the requirements of the Mental Capacity Act 2005, which includes the duty to consult others such as carers, families and/or advocates where appropriate” (Care Quality Commission, 2015).
Mr G as the right to maintain his community presence, and to access activities which will enrich his life, however, the organisation has a duty of care to ensure that he achieves this safely without harm to himself or others. Staff must work within the remit of person-centred, health and wellbeing, and health and safety policies to ensure that guidelines are followed, but must also consider the benefit of positive risk taking for the client, and recognise that everybody has the right to take risk. This can be achieved with careful risk analysis, assessment, and good knowledge of legislation and local policy. There is an expectation that risk, along with outcomes will change at any given time and as such, risk assessment is a continual process.
Responsibility to manage risk.
The organisation has a responsibility to identify and measure risk and to complete risk assessments which document how hazards can be minimised or prevented. “The Health & Safety at Work etc. Act 1974 enforces a general duty on all employers to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees, and others who may be affected by the organisations undertakings” (ISO123, 2017). There is also a responsibility for all staff to follow the Risk Assessment Policy to ensure that all employees are aware of how to record, review and audit risk assessments effectively. This ensures compliance with Management of Health & Safety at Work Regulation 1999.
Duty of care is a term used to define accountability within a job role. In order to maintain high standards of care the duty of care, there should be clear lines of responsibility and accountability for the quality of care. In addition to this the organisation must have accessible clear policies to manage risk and published procedures for each staff group to identify and correct poor performance (Unison, undated). The support planning policy identifies that the organisation must assume that an individual has mental capacity unless this is deemed otherwise in accordance with the Mental Capacity Act 2005. If a best interest’s decision needs to be made about a person’s support because (following the principles of The Mental Capacity Act 2005) they do not have capacity to make a particular decision then this need to be recorded within the support plan, including how the decision was made, who was involved, how the person was involved and why it is believed to be in the best interests of the person. This safeguards against the possibility of decision being taken on behalf of the individual and manages the risk accordingly. Mr G’s risk was managed by being supported to understand his rights, having outcomes of choices explained thoroughly to her in her preferred method, and by working in partnership with family and outside agencies.
Analysis of the consequences of not managing risk effectively
The impact of not non-compliance and failure to manage risk can impact upon the health and wellbeing of the client. In addition to this the organisation could suffer loss of reputation, probable withdrawal of contracts from the Local Authority, financial issues, legal consequences and investigation by the Care Quality Commission. Poor risk management can stem from weak support planning. If client needs have not been assessed and planned properly, then risks may not have been identified. This potentially could occur if the client has not lived in the area for long and is not well known to services, or if the organisation has not complied with policy during the assessment phase. As a consequence the client’s needs are not met, and unknown risk could present. Correspondingly If the problems Mr G is experiencing were simply resolved by preventing him from accessing the community, his health and wellbeing would deteriorate, and his right to take risks would be reduced, but because employees have knowledge from current training, and incorporate local policy into practice, risk is managed in a way that enables Mr G to continue doing the things that are central to his wellbeing.
Similarly, Ineffective management of risk could result in Mr G requiring increased levels of support further reducing his independence. Episodes of challenging behaviour may increase and subsequently trigger isolation and loss of autonomy. If his communication problems were not adequately addressed, the client is at additional risk of not being able to input his own views during the planning of outcomes and reviews, thus affecting the care and support he will receive. Incorporating best-practice into the delivery of care ensures that risk is managed appropriately and that clients accessing health and social care services maximise their potential.
LO4 Understand how good practice in the administration of medication is essential for users of health and social care services
4.1 review current legislation, codes of practice and policy that apply to the handling of medication
4.2 evaluate the effectiveness of policies and procedures within a health and social care setting for administering medication
The administration, storing, recording and disposal of medication can have many challenges, and these are often exacerbated when the organisation does not have a healthy safety culture. Vulnerable client groups accessing health and social care services are dependent upon robust policies and procedures to protect them from harm. This, in part is contingent upon how well the organisation has perceived and translated the law from relevant legislation, and also upon the quality of training that care and support staff have received. Groups of clients, especially those that have intellectual disabilities often have severe communication difficulties or behaviours that challenge, which can raise barriers to both administration, and ascertaining whether medication is working or not. Gaps between policy and practice often present with medication administration. The legislation, which promotes choice, person-centredness, and the right to refuse, can cause conflict and confusion between what is considered duty of care, and actual support being delivered.
Legislation is required to safeguard:
- Individuals receiving medication
- Those who are administering medication
- The organisation
- Other individuals who may have access to medication
Adhering to legislation and guidelines reduces the possibility for medication accidents and supports in reducing medicinal abuse. “There are isolated cases of medication being mismanaged intentionally, such as the misappropriation and misuse of drugs by staff” (Social Care Institute for Excellence, 2012), and this can potentially result in harm to individuals in receipt of care and support, and damage to the reputation of the organisation. The Medicines Act 1968 defines three legal classifications’ of medicines:
- general sales list medicines (GSL)
- pharmacy medicines (P)
- prescription-only medicines (POM)
Within this legislation, the majority of medicines can only be sold or provided with a prescription at a pharmacy under direct supervision of a pharmacist. However, some medicines (GSL) can be sold at other premises, such as convenience stores, as long as they’re pre-packed and the premises can be closed to exclude the public. It’s illegal to sell medicines from market stalls or from vehicles, such as at car boot sales (NHS Choices, 2015). This assists in regulating who can access types of medication. To illustrate this, an individual suffering from a headache would not be able to purchase a prescription only medication from the chemist over the counter and would require a prescription from a doctor. The legislation provides a safety framework, as well as limiting scope for abuse to occur.
Mr G, who is supported by the organisation and has learning disabilities and autism, takes anti-psychotic medication for his severe anxiety. The agency must incorporate national legislation into its own policies and procedures in order to comply with the law. The local medication policy and procedure draws upon numerous pieces of legislation in order in order to apply the law and safeguard the client:
- The Medicines Act 1968
- The Misuse of Drugs Act 1971
- The Misuse of Drugs (safe custody) regulations 1973
- The Health and Social Care Act 2008 (regulated activities) Regulations 2014
- The Handling of Medicines in Social Care – Royal Pharmaceutical Society of Great Britain
- NICE Guidelines – managing medicines in care homes 2014
- The Mental Capacity Act 2005
The Health and Social Care Act 2008 (Regulated Activities): Regulation 12 establishes the need to prevent individuals from accessing unsafe care and treatment and to prevent avoidable harm or risk of harm (Care Quality Commission, 2017), and outlines how medication must be supplied in adequate amounts, managed safely and administered appropriately to ensure that people are safe. This is echoed within the local medication policy which states:
- The organisation will enable a person to take their medication in a safe way
- The organisation will always follow best practice guidelines and legal and statutory responsibilities
- We have secure and accurate protocols for the recording, handling, safe administration and disposal of medicines
The National Institute for Health and Care Excellence define guidelines for the management of medication and highlight the use of the 6 R’s of administration:
- Right Medicine – Double check that the medication being administered is the correct one
- Right route – Check that medication is being given via the intended route (for example creams topically, tablets orally, midazolam buccally).
- Right person – Medicines should only ever be taken by the individual for who they are prescribed. Individuals in shared housing may want to keep their medications in separate places to avoid confusion.
- Right dose – ensuring a colleague has checked the amount of medication being administered.
- Right time – Ensuring that medication is taken at the specified time, and not at a time which is suitable purely for the organisation.
- Right to refuse – respecting the clients right to refuse their medication, yet explaining the health consequences of their decision.
These provide an extra safety mechanism during the giving of medication, and additionally acknowledge the rights of the client. Medication administration should remain just as person-centred as the rest of an individuals’ support to promote control over their own lives. The organisation recognises that each individual has the right to choose if they take their medication. “The attempt to eliminate all risk undermines people’s dignity and inhibits opportunities for personal development and growth” (Maclean, 2012). Where a person is supported with their medication, information is kept within the support plan about how they communicate consent to receive their medication, and this is respected at all times.
NICE also outlines how the organisations’ that directly deliver care services should evaluate local policies, processes and local governance arrangements, ensuring clarity, accountability and responsibility for using medicines safely and effectively in care settings. This includes the necessity to provide a medication policy which should be regularly reviewed and which is based on the most up to date legislation and appropriate guidance. This should comprise:
- sharing information about a resident’s medicines, including when they move to other care facilities
- Ensuring that recorded information is up to date
- Recognising and reporting medication reported problems
- Safety of clients
- Accurately documenting client medication
- The reviewing of medications
- The ordering of medications
- receiving, storing and disposing of medicines
- Supporting clients to store and administer own medication
- Support staff administration of medication, including training and measurement of competency
- Covert medication administration
- Homely remedies (National Institute of Care Excellence, 2014).
The local CoSHH policy identifies the requirement to appropriately handle and store substances which are hazardous to health, and this is echoed within the medication policy. Because Mr G lives within his own home, the least restrictive location must be used to store her medication., and risk is assessed accordingly via the risk assessment process. Mr G chooses to keep his medicines in his own wardrobe and so these are in a locked container in his bedroom. Mr G’s anti-psychotic medication must not be stored anywhere above 25c degrees or below 5c degrees and must not be decanted into any container other than the original packaging it came in. This is to safeguard the client, and reduce the probability of using the wrong medication. Support staff must not secondary -dispense, and therefore When Mr G accesses day services or community support, the medication he takes with him must remain in its original packaging. The only person who may secondary-dispense is Mr G if he so chooses.
The Medicines Act 1968 details appropriate disposal of medicinal products which have become unusable or otherwise unwanted and this is highlighted in the local medication policies stating “Medication should always be returned back to a pharmacies and enquiries with the pharmacy should be made regarding how they expect to recieve out of date and unused medicines. This must be documented”.
Mr G’s health and wellbeing is safeguarded by numerous other statutes which control medication which may be prescribed, and administered to him. The Misuse of Drugs Act 1971 is the chief law to regulate and categorise drugs that are ‘dangerous or otherwise harmful’ when misused. The act lists all illegal (or controlled) drugs in the UK and divides them into one of 3 ‘classes’ – A, B and C – based on the harm they cause to individuals and society (Department of Health, 2015). The Misuse of Drugs (Safe Custody) Regulations 1973 set the minimum storage requirements for some illegal (or controlled) drugs. They apply to care homes and retail pharmacies, and are applied as minimum standards in other healthcare settings (Department of Health, 2015).
Challenges may present with medication or treatment within a health and social care setting. Individuals with learning disability may not fully understand the impact of refusal medical treatment or medication, and therefore it is vital to work in partnership with other professionals supporting Mr G to ensure he is well informed. The General Medical Council states that doctors “must respect a competent patient’s decision to refuse an investigation or treatment, even if they think their decision is wrong or irrational.
Doctors may advise the patient of their clinical opinion, but they must not put pressure on them to accept advice” (General Medical Council, 2017). Although Mr G has autism and moderate learning difficulties, he has mental capacity and therefore it is his right to refuse treatment or medication if he wishes. However, the exercising of rights can cause potential ethical dilemma for staff who are bound by a duty of care to promote the health and wellbeing of clients. Should Mr G refuse his anti-psychotic medication it could result in heightened anxiety and increased challenging behaviour which reduces his quality of life. The local medication policy acknowledges that care staff cannot force an individual to take their medication and advises that if a person has mental capacity to make this decision then information should be provided on the impact of refusal so that the individual can fully understand what may occur as a result. This is in line with the Mental Capacity Act 2005 which recognises that “Just because someone makes what those caring for them consider to be an “unwise” decision, they should not be treated as lacking the capacity to make that decision”.
Each individual has the right to make their own life choices, where they have the capacity to do so. This is in place to empower individuals and to enable people to be in control of their own lives. Recording of the refusal to take medication must be done via an incident form and additionally recorded on the medication administration record using the correct code. If at any point, Mr G no longer has capacity to understand the consequences of his refusal, and this has been established by his social worker, then a decision may have to be taken in his best interests. This may involve administering medication covertly but this should not be initiated until after a best interests meeting has been held. If the situation is urgent, it is acceptable for a less formal discussion to occur between the care home staff, prescriber and family or advocate to make an urgent decision. However, a formal meeting should be arranged as soon as possible (National Institute of Care Excellence, 2015). The covert administration of medicines should only be incorporated as a last resort when such a means of administration is deemed necessary, in accordance with the Mental Capacity Act 2005. The organisation acknowledge this guidance and incorporate it into their own medication policy by stating “The only time medication would be given in this way, would be with a general practitioner or another appropriate health care professional’s opinion that the person lacked the capacity to consent (applying the guidelines of the Mental Capacity Act (2005) to the medication and it was necessary to their health and well-being” (An organisation, 2016).
The policies adhered to within the organisation all reflect National legislation and guidelines to ensure client safety, person-centredness and empowerment. This ensures that continued health and well-being is promoted.
By S.D – written 2017