The Barnardo Rule Book

THE BARNARDO BOOK

CONFIDENTIAL

For private circulation only.

MEDICAL SERVICES

The efficiency and success of a Home depends largely on the maintenance of a high standard of health amongst the children. This can only be secured by the prompt and effective treatment of illness and by constant attention to dietary, daily routine, clothing, and other matters of general hygiene.

Chief Medical Officer. The Chief Medical Officer is responsible to the Council for the general medical policy of the Homes and for the administration of the medical services. His duties include the supervision of the health of the children and the inspection of the sanitary conditions of the Home, the dietary of the children, and such matters as may affect their general health.

Every child will be fully examined at least once a year by one of the Headquarters' Medical Officers.

A Visiting Doctor is appointed to each Reception and Branch Home. His duties include:

(a) A complete medical examination of every child as soon as possible after its arrival.

(b) Periodic routine visits to the Home.

(c) A quarterly inspection of each child. (This does not apply to Reception Homes.)

(d) The treatment of sick children.

(e) Such vaccinations and immunizations against diphtheria as may be required.

(f) Advising as to dietary and hygiene.

(g) The supervision of medical records.

(h) Medical attention to members of staff not covered by a National Health Insurance Panel.

Not more than a week should elapse between the doctor's periodic visits. On these visits he will see such cases of illness as have not required a special visit, and new children admitted to the Home during the week.

At the quarterly medical inspection, all medical dossier cards must be ready for the doctor, duly entered up and with the latest recordings of height and weight. The children should be completely stripped, with the exception of one loose garment, such as pants, and should be barefooted, so that no time need be lost in preparing for the examination. It is important that feet should be examined and the presence of chilblains, sores or commencing deformities noted.

The examination should take place in the "surgery" or an adequately warmed room, and on a wood or carpeted floor. The Superintendent should have a list of the children's names so that he may check off each child as seen, and make such notes as desired by the doctor.

For children of school age advantage should be taken of the School Medical Officer's routine examinations, and these may take the place of one of the quarterly inspections in the Home.

The appointment of a visiting doctor does not divest RC Superintendents of their general responsibility for the children's health. The Superintendent will ensure that all sick children and newly admitted children are brought to the notice of the doctor; that weights and heights are taken and recorded on the dossier card, and that the children are prepared for the quarterly examination. He is responsible for the correct keeping of medical records and reports, and sending such reports as may be called for to the Chief Medical Officer.

A Medical Record Book must be kept in each Home. In it will be entered a permanent record of the health of each child on admission, his or her medical history while in the Home, and the state of health on transfer to another Home or situation. At the same time the child's individual medical dossier must be kept constantly up to date, showing the latest records of height and weight with the important items of his or her medical history.

A Daily Record Book must also be kept showing the names of all children given treatment of any description, as well as a record of those seen by the doctor.

The Chief Medical Officer requires the following Reports:

i. A short monthly report on the health of the Home.

ii. A quarterly report on the health of each child, including trainees, in the Home with a record of its height and weight.

iii. An immediate report on any accident that has occurred.

iv. Immediate notification of infectious diseases.

v. Immediate notification of cases of serious illness, including all cases requiring removal to hospital.

vi. Notification of deaths, with a report from the doctor, and the findings of any post-mortem examination or inquest that may have been held.

On arrival, the Superintendent, or other member of the staff appointed by him, should ascertain that the child is entirely free from any appearance of eye, skin, or other infectious disease. If any infectious disease is suspected the child should be isolated at once pending the visit of the doctor.

Immediately following the reception of a new child the doctor must be notified, and the complete examination of the child must take place within forty-eight hours. Where for any reason this is not possible, a special note of the circumstances must be made in the medical record book. The doctor at his examination will fill in the child's medical dossier card, noting any defects which may require treatment, and any marks or evidence of previous injury. After a quarantine period of four weeks, children will pass from the Regional Reception Centre to the Central Reception Home. Before such transfer, they must be seen and passed by the doctor not earlier than forty-eight hours before departure.

At the Central Reception Home. After arrival from the Reception Centre children will be given a detailed physical and psychological examination. Treatment for any defect already noted on the dossier card or found at this examination, will then be carried out. On the findings of this examination, and after a period of observation, children will be allocated for either boarding-out, Branch Homes, or special Homes. Before transfer from the Central Reception Home each child must be seen, not earlier than forty-eight hours before departure, by the medical officer and passed as fit.

If, after allocation, cases of serious behaviour or psychological problems arise in children sent boarding-out or to Branch Homes they may be recalled to the observation centre for reconsideration or treatment.

At a Branch Home. Children will normally be received from the Central Reception Home and will be accompanied by a detailed medical report. Their arrival must be notified to the doctor who will see them at his next routine visit, when their dossier cards and medical reports will be available; he can then issue instructions as to any special care or treatment required. Before transfer to another Home or to Headquarters for a situation or restoration, and not earlier than forty-eight hours before departure, all children must be examined by the doctor and certified by him as fit for transfer.

Slight cases of sickness or indisposition frequently occur among children and in many cases can be dealt with by the Superintendent or the staff, especially if this includes a trained nurse. It must largely be left to their discretion to decide which cases require the attention of a doctor, but in any case in which it is found necessary to keep a child in bed, not more than twenty-four hours should be allowed to elapse before he is informed of the details and no case of sickness or indisposition, however slight, should be allowed to continue for more than a week without being brought to his notice. In the case of skin complaints, it must be emphasized that the main and elementary duty of the staff, whether they are trained nurses or not, is to recognize at the earliest possible stage that some form of skin disease is present and to bring the case promptly before the doctor for diagnosis and treatment. This is especially important where scabies, impetigo or ringworm of the scalp are concerned. The aim of anyone undertaking nursing duties, whatever her qualifications, should be the early recognition of the need for medical advice, prompt reference of the case to the doctor and strict adherence to his instructions.

In cases where the doctor considers that a second opinion should be obtained, and recommends reference to a consultant, Superintendents will make the necessary arrangements for the child to be seen either at the Home or at a convenient General Hospital, acting on the advice of the doctor as to the most suitable place and person to whom to refer the patient. A full report should at once be sent to the Chief Medical Officer.

Permission must be obtained from the Chief Medical Officer before any surgical procedure is undertaken, except in cases of emergency when the Superintendent of the Home may give the necessary consent to the Hospital Authorities. In normal cases Superintendents must notify the Chief Executive Officer at least seven days before the operation to enable him to communicate with the child's relatives.

The weighing and measuring of children is a most important means of estimating their physical progress, and must be carried out at regular intervals—every three months. This should be done shortly before the doctor's quarterly inspection and the names of any children who have failed to make progress should then be reported to the doctor. To ensure uniform results, heights should be taken in bare feet or in stockings, and weights in a single garment. It is also important that weights should be taken on each occasion at about the same time of day. The best time to weigh is after breakfast—say on a Saturday morning. It is not necessary to arrange to weigh each child quarterly as from his or her birthday; the better plan is to weigh all children on the same day and thereafter quarterly, paying due attention to the results both for individuals and for the group as a whole. It must be recognized that an apparent satisfactory gain in weight and height is not sufficient if poor stance and a slouching gait evidence a muscular tone below normal. Attention must be paid to the physical side of recreation ensuring for each child an adequate amount of outdoor and wisely directed muscular activity.

A Dentist is appointed for each Home. He will make a six-monthly examination of all teeth. Children reported by the Dentist at these examinations as requiring attention should be specially noted and brought up to him for treatment in accordance with his instructions. A record of all dental work done, including inspection of teeth should be kept.

Each Home should set aside separate quarters to which sick children can be admitted for observation and treatment, or for isolation in the case of infectious diseases. In the control of outbreaks of infectious or contagious diseases it is the early recognition, and prompt and effective isolation, of the first case which counts. For sick rooms in the smaller Homes two or three well spaced beds should suffice; in larger Homes five beds for 100 children, preferably in two rooms, would be required, and so up to ten beds for 200 children in two or three rooms. These rooms should be located close to a bathroom and lavatory, which can in cases of infectious disease be devoted entirely to their use. Provision should be made for the storage of milk and essential foods near by, and all crockery and cutlery should be kept, washed and if necessary, disinfected close to the sick room. Baths and lavatory in sick quarters are to be reserved exclusively for their purpose.

A room should also be allocated for use as a "surgery" for daily dressings and examinations. In it should be kept, in a properly locked up cupboard, all supplies of medicines, lotions and ointments; and it should be provided with means for boiling water for sterilizing the simple instruments in use, and for the preparation of fomentations, etc. This room need not be large, but should be well lighted and warmed; it will be used by the doctor and all his routine examinations will be conducted there; therefore it should have provision for the storage of all medical records.

A clearly defined and regular routine must be adhered to both in regard to the custody and issue of all medicines. Only such medicines as are ordered by the doctor should be given to the children, and his instructions must be strictly followed. The custody and issue of all medicines should be the duty of the Senior Matron or Nurse; this duty should in no circumstances be delegated to unqualified junior assistants or probationers, unless they are under personal supervision. Poisons must be kept in a separate locked cupboard.

In the planning of sleeping accommodation, 40 sq. ft. Gene per bed is the minimum requirement which can be accepted as reasonably effective in limiting the spread of infectious diseases. In irregularly shaped rooms this standard may be difficult to and1 apply; a satisfactory alternative is to allow a minimum distance Vent of 5 ft. between bed centres, irrespective of age. Beds must be so placed as to allow each child easy access to the doorways and fire exits. Adequate ventilation at night must be assured, care being taken to see that the children are warmly covered. Each child should have an under-blanket and a minimum of three top-blankets. During the day full ventilation should be obtained and blankets and mattresses brought out, as opportunity offers, for thorough airing and sunning. Dust rapidly accumulates in the dormitories, much of it from the blankets, and soon tends to become heavily infected with organisms; it is very necessary therefore that all blankets should be regularly shaken, and sent for disinfection at regular intervals.

Children will not thrive unless they have ample sleep at regular hours. A late night now and again will not matter if you see that the child makes up for it at other times. Remember that the quality of sleep is just as important as its quantity. Sleep that is restless and disturbed is of very little value. The great disturbers of sleep are noise and anxiety. Keep the house as quiet as possible when the children have gone to bed and do not have the wireless turned on louder than necessary. Do your best to see that the home atmosphere is one of security and avoid conversations which are likely to alarm or worry children.