Homely Remedies Guidance

Homely Remedies Guidance Guidance from the Royal Pharmaceutical Society of Great Britain (RPSGB) in The Handling of Medicines in Social Care, states that care homes are able to purchase medicines for use within the home as homely remedies. It is emphasised however, that this must be subject to careful control. The homely remedy list should be agreed in conjunction with the service user s general medical practitioner, the community pharmacist and the home. This document has been produced as a guide to be used when developing your own Homely Remedies policy. It aims to highlight the areas which should be considered during the development process and to encourage safe working procedures and best practice. It is not intended to be used without further input from each individual care home, GP, community and Care Homes Pharmacist. Homely Remedies is another name for non-prescription medicines available for the short-term treatment of minor ailments such as indigestion, coughs, mild to moderate pain and constipation. They are usually purchased by the care home or the resident and can be administered to patients without being prescribed by a doctor. Advice from a healthcare professional, such as a GP or pharmacist, on the use of homely remedies should be taken for each resident in advance, or at the time of need. If the healthcare professional deems a patient unsuitable for treatment with any of the remedies kept within the home or decides that their clinical condition warrants early escalation rather than management with homely remedies, this should be noted in their care plan. The care plan should therefore be consulted before giving a homely remedy to any resident. Administration of homely remedies should be limited to a period of 48 hours and should be given in accordance with the patient information leaflet for each product. Any further doses required after the initial 48 hour period will necessitate discussion with the GP to re-assess the patient s condition. Any medication administered must be clearly recorded on the patient s medication administration record chart (MAR chart) and brought to the attention of the subsequent senior person on duty. The decision to administer the remedies should be made by the senior person on duty prior to each dose. The senior person must ensure that there are no contra-indications before giving the medicine to the resident, taking in to consideration any changes which may have been made to the medication regimen since the last dose. 1

All care home staff using a homely remedies protocol should be named in it and that they should sign to confirm they are competent to administer the medicine, acknowledging that they will be accountable for their actions. Agreement on the part of the GP to authorise the use of the homely remedies outlined in this document does not necessarily mean that they will or will not be prepared to issue a prescription if treatment is to continue. In some cases, GPs may recommend that homes purchase products overthe-counter, specifically for the use of one particular patient. Under these circumstances the medication should be labelled accordingly and should NOT be used for any other resident. Obtaining Homely Remedies 1. Homely remedies can be purchased either for an individual or for stock. A record should be kept of purchases made (see appendix 2). 2. There are two categories of homely remedy: GSL (general sales list) which are widely available from supermarkets, pharmacies and other stores; and P medicines (pharmacy) which are only available from a community pharmacy. 3. Products requiring invasive administration e.g. suppositories should not be included nor is appropriate to include products that take longer (up to 48 hours) to work e.g. lactulose. 4. External preparations should be excluded as they should only be used by one individual to avoid across contamination. 5. Dressings, items for first aid, vitamin supplements, herbal and homeopathic preparations are not homely remedies. (Note that residents may wish to purchase vitamin supplements, herbal or homeopathic preparations for their own use long-term. This should be discussed with the service user s GP and documented accordingly). Storage of Homely Remedies 1. All homely remedies MUST be stored in their original packaging together with any information supplied with the product about the medicine use. 2. Homely remedies must be stored in a locked medicine cupboard. 3. Homely remedies should be kept in an area separate from prescription medicines, in a labelled area or box within the medicine cupboard. 4. Excessive quantities of homely remedies should not be stored by care homes 5. Homely remedies should be stored at temperatures below 25ºC (unless stated otherwise) away from damp and light in accordance with the patient information leaflet or instruction on the packaging. 6. If the homely remedy is kept in a resident s room it should be stored in a lockable drawer or cupboard. 2

7. Access to the homely remedies should be restricted to staff with medicines management responsibilities. The policy for use should be easily accessible. 3

Administration of Homely Remedies The administration of a homely remedy can be in response to a request from the resident or from a member of care home staff. The National Care Forum has treatment flow charts which can be agreed locally and adapted for local use, they are available at: http://www.nationalcareforum.org.uk/medsafetyresources.asp 1. It is the responsibility of the senior carer or duty nurse to check that the administration of the homely remedy is appropriate. If there is any uncertainty the GP or pharmacist should be consulted and the discussion documented. 2. If the resident self administers the homely remedy a risk assessment must be completed and kept with their care plan. 3. The administration of homely remedies must be recorded according to the care home policy and procedures. The resident s MAR chart should be used if it is possible. The entry should be annotated homely remedy. It should be clear what was given, when it was given, who administered it and why it was administered, as well as the effect of the medication. This is particularly important to enable staff to determine when the last dose was given, avoiding accidental overdose, and to monitor effectiveness. 4. The document used to record the purchase of the medicinal product should be updated to indicate that it has been administered to a resident (see Appendix 2). 5. Homely remedies should be given for a limited period, usually 48 hours or the period stated in the medicines policy. 6. Once opened, all liquids should have the date opened recorded on the container. Liquids should be discarded less than 6 months after opening unless otherwise stated by the manufacturer (see Care Homes SOPs 18a and 18b for details on medication disposal). Recording Homely Remedies Stock records should be kept of all homely remedies. This may be achieved by keeping a homely remedies book, with a separate section devoted to each remedy stocked (See Appendix 2). In this book records are kept of: Date obtained Quantity obtained Name of resident homely remedies given to Dose given to resident Reason for use Stock balance Date, quantity and expiry date checked by Signature of person administering and/or It is important to ensure that correct records are made both on the MAR chart and stock register. 4

Audit The balance and expiry dates of the homely remedies must be checked regularly. It is good practice to check these monthly. Note that some products may have a shorter shelf life once opened, check the manufacturer s literature. Disposal Expired stock should be disposed of in line with the care home s policy on the disposal of medication. (see Care Homes SOPs 18a and 18b for details on medication disposal). Review 1. The resident should be reviewed if the homely remedy is required beyond the agreed period, usually 48 hours (or 24 hours if symptoms of diarrhoea are present and fluid intake is poor), or sooner if clinically indicated. 2. If the resident is not examined by the GP but it has been agreed that treatment should continue, the GP should confirm this in writing (e.g. fax or email). Resident purchases of his/her own supply of OTC medicines. 1. OTC medicines are those which can be purchased over the counter, in a pharmacy or other retail outlet. 2. Residents and their relatives should be encouraged to inform staff of all these medicines entering the home. 3. The safety, storage and recording issues must be discussed and explained, but without invading the patient s privacy. 4. The use of such medicines is outside the scope of this guidance and separate policies should be developed by the home in conjunction with the GP and community pharmacist First aid Homely remedies should not be confused with products used for first aid. First aid boxes must comply with The Health & Safety (First Aid) Regulations 1981. 5

Developing a Homely Remedies list. This table serves as a guide for use when developing your own homely remedies list. It may be decided that items are deleted from this list and other medications added. This should be done only after full discussion and agreement with your servicing GP and Community Pharmacist. The following pages show the detail required for any medication which is subsequently added to your list (See Appendix 1). It must also be decided in conjunction with the GP how often they wish to review the medications in the homely remedies list. The local Pharmacist and GP should indicate if any chosen medication is unsuitable for any of their patients in the home, and the medication record should be annotated accordingly. Once the list has been developed, the GP, Community Pharmacist and Home representative should sign a copy of the agreement form (see Appendix 1). Minor ailment requiring treatment For aches and pains, headaches, colds, sore throats and fever. For indigestion Medicine Paracetamol 500mg Tablets OR Paracetamol 250mg/5ml Suspension Sodium alginate/ Potassium carbonate suspension Brands include: Gavison Advance and Peptac Dose 500mg-1gram every 4 to 6 hours (Maximum 4g in 24 hours) 5 to 10 ml after meals and at bedtime (Maximum 40mL in 24 hours) For coughs Simple Linctus (sugar-free) 5 to 10 ml taken 3 to 4 times daily (Maximum 40mL in 24 hours) For diarrhoea Oral Rehydration Solution One or two sachets reconstituted according to manufacturer s guidelines. Sip regularly as required. For constipation Senna 7.5mg tablets 7.5 to 15mg taken At night OR Senna 7.5mg/5mL liquid Maximum 15mg in 24 hours 6

NAME OF HOME. SIGNATURE OF MANAGER OF HOME.. DOCTOR NAME / PRACTICE NAME.. SIGNATURE OF DOCTOR. NAME OF CARE HOME PHARMACIST SIGNATURE OF CARE HOME PHARMACIST. DATE.. Acknowledgements: Redditch and Bromsgrove Primary Care Trust Boots the Chemist Tania Cook Medicines Management Team NHS Nottingham City CCG References: 1. RPSGB The Handling of Medicines in Social Care 2. British National Formulary No 72 September 2016-March 2017 3. NHS PrescQIPP Bulletin 72 Care Homes Homely Remedies August 2014 7

Appendix 1: Example of homely remedy agreement form Care home name: GP practice name: I agree that a suitably trained senior person on duty at [insert care home name] may administer the medication listed above for the indications stated, to [insert name of patient] OR [delete one sentence as applicable] I [insert GP name] agree that a suitably trained senior person on duty at [insert care home name] may administer the medication I have authorised in this form for the indications stated, at the dose stated and for appropriate patients under my care at [insert care home name]. This agreement does not remove the requirement that staff involved in the administration of homely remedies must ensure that the medicine to be administered is suitable for the resident s particular circumstances at the time of administration. The homely remedy should not be used for longer than 48 hours without seeking medical attention. SIGNATURE OF MANAGER OF HOME.. DATE.. SIGNATURE OF DOCTOR DATE.. 8

Homely Remedies List Product Indication Adult dose Maximum daily dose Additional information Please indicate which products have been authorised (and annotate those that are excluded) Sodium alginate/ Potassium carbonate suspension (e.g. Gavison Advance and Peptac) For the relief of heartburn or indigestion 5 10 mls after meals and at bedtime 40mls in divided doses Sodium and potassium content should be taken into consideration if a highly restricted salt diet is recommended. Senna 7.5mg tablets For the relief of constipation 1 2 tablets (usually) at night 2 tablets May colour urine Senna syrup (7.5mg/5mL) For the relief of constipation 5 10mls (usually) at night 10mls May colour urine Paracetamol 500mg tablets (also caplets & capsules) For the relief of mild to moderate pain or raised temperature 1 or 2 tablets every 4 to 6 hours, up to a maximum of 8 in 24 hours. 4g (8 tablets) in divided doses Do not give with other paracetamol containing products. 9

Product Indication Adult dose Maximum daily dose Additional information Please indicate which products have been authorised (and annotate those that are excluded) Paracetamol 250mg/5ml oral suspension For the relief of mild to moderate pain or raised temperature 10 20mls every 4 6 hours, maximum of 4 doses in 24 hours. 80mls in divided doses Do not give with other paracetamol containing products. Simple linctus sugar free For dry irritating cough 5 10 mls up to 4 times a day (suitable for diabetics) 40mls in divided doses Not suitable for productive coughs. Oral rehydration sachets For treatment of fluid and electrolyte loss associated with acute diarrhoea One or two reconstituted sachet(s) after each loose motion 20-40ml/kg The solution may be refrigerated for up to 24 hours after which it should be discarded. 10

Paracetamol Tablets/Suspension A non-opioid drug, paracetamol is a suitable first choice for analgesia for most patients with mild to moderate pain. In normal therapeutic doses it is well tolerated and effective. It has antipyretic properties and appears to act centrally but with no anti-inflammatory effects. 1. Clinical condition / indication(s) for use i. Patients with generalised symptoms of pain ii. Fever 2. Patients eligible for inclusion in the policy: i. Any patient requesting relief from mild to moderate pain and/or fever. 3. Patients excluded from the treatment under the policy: i. Liver disease ii. Kidney disease iii. Alcohol dependence iv. Prescription of any other drugs containing paracetamol, i.e. co-dydramol, co-proxamol, co-codamol. Also check prior intake of the over-the-counter paracetamol and paracetamol containing products, especially cold and flu remedies. Over dosage with paracetamol is particularly dangerous as it may cause hepatic (liver) damage, which may not be apparent for 4 to 6 days 4. Action for patients excluded from the treatment under the policy: i. Any patient should be reviewed by medical staff and alternative medication prescribed. Discussion with the GP may also be warranted in the following situations: If pain or fever has not subsided following administration of paracetamol, or if pain increases in severity following administration of Paracetamol, notify medical staff. NB Soluble tablets have a high sodium content so should be avoided. 11

Sodium alginate/ Potassium carbonate suspension (e.g. Gavison Advance and Peptac) Antacids often relieve symptoms in both ulcer and non-ulcer dyspepsia and in gastro-oesophageal reflux disease. Usually given 20-60 minutes after meals and at bedtime, or when required. 1. Clinical condition / indication(s) for use: i. Heartburn ii. Indigestion 2. Patients eligible for inclusion in the policy: i. Indigestion symptoms including heartburn or food-related discomfort. 3. Patients excluded from treatment under the policy: i. Any patient who might be suffering from something other than simple indigestion e.g. heart pain or severe abdominal pain; patients with recurrent/persistent symptoms; patients taking regular NSAID or aspirin or if vomiting or weight loss are present should be immediately referred to the GP ii. Patients already prescribed medicines for heartburn/indigestion eg Peptac suspension. Do not administer at the same time as other medicines as it may impair their absorption, it may also damage enteric coated (e/c) tablets. Life style advice o Reduce intake of fat, coffee, chocolate and spices. o Avoid food and drink 2-3 hours before bedtime. o Avoid smoking and alcohol. o Avoid bending and stooping. o Raise head of bed 4-6 inches. o Avoid tight abdominal clothing. Staff to note the date of opening on the bottle and dispose of after appropriate length of time (6 months after opening or manufacturers expiry datewhichever is shorter). 12

Simple Linctus (sugar-free) Demulcent cough preparations contain soothing substances such as syrup or glycerol. Some patients find they relieve an irritating cough especially useful during the daytime. 1. Clinical condition / indication(s) for use: i. For patients needing something soothing for irritating troublesome cough 2. Patients eligible for inclusion in the policy: i. as above 3. Patients excluded from treatment under the policy: i. not applicable 4. Action for patients excluded from treatment under the policy: i. Discuss with the GP if a troublesome cough does not subside within 24 hours. ii. GP should be consulted immediately if the patient appears mentally confused, very unwell or distressed, has one sided chest pain which is worse on coughing or deep breathing. iii. Other causes for concern include moderate to severe breathlessness, chest pain, cyanosis, pallor, asthmatic patients. Consider drug induced cough e.g. from Angiotensin Converting Enzyme Inhibitors such as Captopril, Enalapril, Lisinopril, Ramipril. Staff to note the date of opening on the bottle and dispose of after appropriate length of time (6 months after opening or manufacturers expiry datewhichever is shorter). Life style advice: o Drink plenty of fluids (but not milk or alcohol) o Use steam inhalations 2-3 times daily o Avoid cigarette smoke - patient s and other people s. Stopping smoking will help prevent future attacks 13

Oral Rehydration Solution There are various oral rehydration solutions available, these solutions should be reconstituted as per the manufacturer s instructions and discarded no later than 1 hour after preparation unless stored in a refrigerator when it may be kept for up to 24 hours. 1. Clinical condition / indication(s) for use: i. Diarrhoea 2. Patients eligible for inclusion in the policy: i. Patients with diarrhoea 3. Patients excluded from the treatment under the policy: i. Patients with inflammatory bowel disease. ii. Patients with active ulcerative colitis or antibiotic-associated colitis iii. Severe hepatic impairment iv. Patients with bloody diarrhoea. v. Patients with diverticular disease vi. Patients who appear severely ill or dehydrated People with diabetes 4. Action for patients excluded from treatment under the policy: i. Seek medical advice and give plenty of fluids. Life style advice: o The solution should be given in small frequent doses in sips. If symptoms last more than 24 hours then medical advice should be sought. o Diarrhoea illness outbreak within a home may indicate a more serious cause, in these situations medical advice should be sought. Recommend washing hands after using the toilet. Wash drinking glasses well. o Clear fluids only should be given for 12 hours. After 12 hours progress to high-calorie, low fibre, milk-free diet e.g: Jelly, clear soup, bread, boiled rice, porridge made with water etc. 14

Senna Tablets/Liquid Senna is a stimulant laxative that works within 8-12 hours, therefore it should be given at night. It increases intestinal motility and can cause abdominal cramp. Excessive use of stimulant laxatives can lead to diarrhoea. 1. Clinical conditions / indication(s) for use : i. Constipation 2. Patients eligible for inclusion in the policy : i. Patients with constipation 3. Patients excluded from treatment under the policy: i. Constipation accompanied by other symptoms, i.e. abdominal pain/vomiting, pr bleeding etc. ii. Pregnancy Urgent referral to a GP is required: iii. If constipation is associated with vomiting, loss of appetite, inability to pass wind or abdominal swelling, as these symptoms could indicate a more serious blockage (intestinal obstruction). iv. Patients who have had previous abdominal operations v. Sudden change in bowel habit and/or weight loss occur 4. Action for patients excluded from treatment under the policy: I. Discuss with GP if constipation continues or is a regular problem. Life style advice: o Increase fluid intake and fibre content of diet (Consult with Care Homes Dietician if necessary) o Increase mobility/exercise where appropriate o Ask your local pharmacist/care Homes Pharmacist/GP to review drugs to identify possible causes (painkillers containing codeine or related drugs often cause constipation). 15

Appendix 2: Record of homely remedies and audit sheet Name and strength of homely remedy Please use one sheet per product Date obtained Quantity obtained Date administered to resident Name of resident homely remedy administered to Dose administered to resident Administered by Balance Date, quantity and expiry date checked by NB 1. Note some products may have a shorter shelf life once opened, check the manufacturer s literature. Record the date of opening clearly on the bottle. 2. For residents who purchase they own homely remedies, record separately to those purchased and stocked by the care home 16

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