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PEG (Percutaneous Endoscopic Gastrostomy) Care and Management Policy

1. Purpose

At {{org_field_name}}, we are committed to delivering safe, effective, and person-centred PEG care to individuals who require enteral feeding via a Percutaneous Endoscopic Gastrostomy (PEG) tube. This policy ensures that all PEG care and management are carried out with dignity, safety, and clinical excellence, in line with CQC regulations, NICE guidelines, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the Mental Capacity Act 2005.

Our aim is to promote safe feeding, maintain skin integrity, prevent infections, and support individuals to live as independently as possible while receiving PEG care.

2. Scope

This policy applies to all permanent, temporary, agency and bank staff, and any other workers who are authorised to provide PEG care or support to individuals receiving services from {{org_field_name}}.

For the purposes of this policy, PEG care means the care and management of an established gastrostomy tube in accordance with the individual’s assessed needs, care plan, prescribed enteral feeding regimen, medicines instructions, manufacturer’s instructions and instructions provided by the relevant healthcare professionals.

This policy covers:

• routine care of an established PEG or other gastrostomy tube where this forms part of the individual’s commissioned care and support;
• administration of prescribed enteral feed and water;
• administration of medicines through a gastrostomy tube where this has been specifically authorised;
• PEG site care and infection prevention;
• monitoring of nutritional and hydration needs within the staff member’s role;
• identification and escalation of PEG-related complications;
• prevention and management of tube blockage within the staff member’s competence;
• action in the event of suspected displacement or accidental removal;
• risk assessment and emergency planning; and
• recording and reporting of PEG care.

Insertion of a PEG tube is not undertaken by support workers under this policy.

Replacement or reinsertion of a gastrostomy tube must only be undertaken by an appropriately trained and competent healthcare professional, or by another person where there is an explicit, clinically authorised procedure permitting this, the activity is within the provider’s lawful scope of practice and registration, and the person undertaking it has received specific training and has been formally assessed as competent.

Staff must not undertake any PEG-related procedure that falls outside their role, training, assessed competence, the individual’s care plan or the provider’s scope of registration.

3. Related Policies

• SL12 – Safe Care and Treatment Policy
• SL07 – Person-Centred Care Policy
• SL21 – Medication Management and Administration Policy
• SL16 – Infection Prevention and Control Policy
• SL08 – Dignity and Respect Policy
• SL34 – Confidentiality and Data Protection (GDPR) Policy
• SL13 – Safeguarding Adults from Abuse and Improper Treatment Policy

4. PEG Tube Care and Management

4.1 Person-Centred PEG Care Plans

Every individual who requires support with PEG feeding or PEG management must have an up-to-date, individualised care plan based on an assessment of their needs, risks, preferences and clinical instructions.

The individual must be involved in developing and reviewing their care plan to the maximum extent possible. Where appropriate and with the individual’s consent, or where there is other lawful authority, relevant family members, representatives and healthcare professionals should also be involved.

The care plan must clearly identify:

• the reason for the gastrostomy and the purpose of enteral feeding;
• the type of gastrostomy tube in use and, where available, its size and relevant device details;
• the individual’s prescribed feeding regimen, including the type of feed, amount, frequency, timing and method of administration;
• the prescribed water and hydration regimen, including the type and volume of water to be used for flushing and additional hydration;
• any fluid restriction or other clinical restriction;
• whether the individual takes any food, drink or medicines orally and any associated swallowing or aspiration precautions;
• the individual’s required position during feeding and for the prescribed period following feeding;
• the method staff must use to identify the expected position and integrity of the tube, including any external centimetre marking or other reference point where applicable;
• the individual’s PEG-site care arrangements;
• whether rotation and/or advancement of the tube is required, the method and frequency, and any circumstances in which it must not be carried out;
• medication administration instructions for medicines authorised for administration through the tube;
• known allergies, intolerances and relevant medicine-feed interactions;
• signs of feed intolerance, dehydration, overhydration, aspiration, infection, blockage, leakage, displacement and other complications that staff must monitor;
• the action staff must take if a complication or change is identified;
• emergency contact and escalation arrangements, including relevant community nursing, enteral feeding, dietetic, GP, NHS 111 and emergency services arrangements where appropriate;
• the individual’s consent to PEG care;
• any relevant Mental Capacity Act 2005 assessment and best-interests decision where the individual lacks capacity for a particular decision;
• the individual’s communication requirements and any reasonable adjustments required;
• the healthcare professionals responsible for reviewing the individual’s enteral feeding and gastrostomy care; and
• the agreed review arrangements.

Nutrition, hydration and PEG-related risks must be reviewed when the individual’s needs change, following a PEG-related incident or complication, following a change in tube or feeding regimen, following relevant healthcare advice and at the review intervals specified in the individual’s care plan.

Staff must follow the current care plan and must not independently change the type or amount of feed, water, medication, feeding method or clinically prescribed PEG-care procedure.

4.2 Feeding via PEG Tube

PEG feeding must only be carried out by staff who have received appropriate training and have been assessed as competent to perform the procedure required by the individual.

Staff must follow the individual’s current prescribed enteral feeding regimen and care plan. Feed must not be changed, diluted or substituted unless this has been authorised by an appropriate healthcare professional.

Before each feed, staff must:

• obtain the individual’s consent in accordance with Section 4.4;
• perform effective hand hygiene;
• confirm the correct individual, feed, prescribed amount, feeding method and time;
• check the expiry date and integrity of the feed and feeding equipment;
• inspect the gastrostomy site and visible tube for leakage, damage, excessive movement, pain, redness, swelling, bleeding or other signs of complication;
• confirm the expected external position of the tube using the method recorded in the individual’s care plan, such as the documented centimetre marking where applicable;
• ensure that all required clamps, connections and enteral feeding equipment are correctly positioned;
• ensure that the individual is positioned in accordance with their assessed aspiration precautions and care plan; and
• confirm that there is no reason why the tube should not be used.

Staff must not routinely use aspiration of gastric contents as an alternative to the individual’s prescribed gastrostomy-position checks.

If the external position has changed, the tube has become dislodged, there is unusual movement, significant leakage, new bleeding, significant pain, abdominal swelling, resistance when flushing or any uncertainty about the position or safety of the tube, staff must stop and must not administer feed, water or medicines through the tube until advice has been obtained from an appropriately qualified healthcare professional and the tube has been confirmed as safe to use.

Following displacement or replacement of a gastrostomy tube, staff must not regard obtaining gastric aspirate or a pH result alone as confirmation that the replacement tube is correctly positioned.

The tube must be flushed using the type and volume of water specified in the individual’s care plan or current clinical instructions. Sterile water must not be used as an automatic requirement for every individual. The appropriate water must be determined according to clinical circumstances, the type and position of the tube, local clinical guidance and the person’s individual requirements.

Feeds must be administered using the feeding method prescribed for the individual, such as pump-assisted, gravity or syringe/bolus feeding.

During feeding, staff must:

• maintain the individual’s prescribed position;
• observe the individual for signs of discomfort, nausea, vomiting, coughing, respiratory distress, abdominal distension, leakage or other signs of intolerance or complication;
• ensure that feeding equipment remains correctly connected; and
• stop the feed and seek appropriate advice if a significant concern develops.

After feeding, the tube must be flushed with the type and amount of water specified in the individual’s care plan. The individual must remain in the prescribed position for the period identified in their care plan.

The feed administered, water flushes and the individual’s tolerance of the feed must be recorded contemporaneously.

4.3 Medication Administration via PEG

Medicines must only be administered through a PEG or other enteral feeding tube by staff who are authorised to administer medicines and who have been trained and assessed as competent in enteral medicine administration.

Every medicine intended for administration through an enteral feeding tube must have clear instructions confirming that the formulation and method of administration are appropriate for that individual and that type of tube.

Staff must not assume that a liquid medicine is automatically suitable for administration through a PEG tube.

Tablets or capsules must not be crushed, opened, dispersed or otherwise altered unless the method has been specifically authorised following appropriate prescribing or pharmaceutical advice and is documented in the individual’s medication instructions or care plan.

Modified-release, enteric-coated, cytotoxic, hormonal or other medicines for which alteration may present a clinical or staff-safety risk must not be crushed or opened unless specific specialist advice has been obtained and documented.

Before administering a medicine through the PEG, staff must check:

• the individual’s identity;
• the current prescription and MAR;
• the medicine, dose, route, time and formulation;
• any medicine-feed interaction instructions;
• whether the feed must be stopped before or after administration;
• the prescribed flush volume and type of water;
• any fluid restriction; and
• that the tube is safe to use.

Medicines must be prepared and administered separately unless an appropriately authorised instruction expressly states otherwise.

Different medicines must not be mixed together in the same syringe or container.

The tube must be flushed before medicine administration, between individual medicines and after the final medicine using the type and volume of water specified in the individual’s clinical instructions. Flush volumes must take account of any prescribed fluid restriction.

Only enteral syringes and equipment designed for connection to an enteral feeding system must be used for enteral administration.

Staff must never force a medicine or water through a tube where resistance is encountered.

Where a medicine cannot be administered safely through the tube, staff must not improvise. Advice must be obtained from the prescriber, pharmacist or other appropriate healthcare professional.

All medicines administered through the PEG, omissions, refusals, administration difficulties, adverse effects and relevant actions must be recorded in accordance with the Medication Management and Administration Policy and the individual’s MAR.

4.4 Consent, Mental Capacity and Best Interests – NEW SECTION

PEG feeding, PEG site care, flushing and administration of medicines through a PEG constitute care or treatment and must only be provided with valid consent or another lawful basis.

Staff must presume that an adult has capacity to make a decision unless it is established otherwise in accordance with the Mental Capacity Act 2005.

A diagnosis, disability, communication difficulty, learning disability, autism, dementia or the fact that a person has a PEG tube must never, by itself, be treated as evidence that the individual lacks capacity.

The individual must be provided with information about PEG care in a form they can understand and must be given appropriate support and reasonable adjustments to enable them to make their own decision wherever possible.

Consent is an ongoing process. Staff must remain alert to verbal and non-verbal indications that the individual no longer consents to an intervention.

Where there is reason to doubt an individual’s capacity to make a particular PEG-related decision, a decision-specific and time-specific capacity assessment must be completed by an appropriate person in accordance with the Mental Capacity Act 2005.

Where the individual lacks capacity for the relevant decision, any decision made or action taken on their behalf must:

• be made in accordance with the Mental Capacity Act 2005;
• be in the individual’s best interests;
• consider the individual’s past and present wishes, feelings, beliefs and values;
• involve relevant people where required and appropriate;
• consider whether the intended outcome can be achieved in a less restrictive way; and
• be properly documented.

Staff must follow any valid and applicable advance decision, decision of an authorised attorney or deputy, or other legally binding decision relevant to the individual’s care.

Family members must not be asked to provide consent on behalf of an adult merely because they are the person’s relative or next of kin. Their views may be relevant to a best-interests decision, but they can only make the decision themselves where they hold the necessary legal authority.

Any restrictions associated with PEG care must be individually assessed, lawful, necessary, proportionate and the least restrictive available option.

5. Infection Prevention and PEG Site Care

5.1 PEG Site and Tube Care

Staff must perform PEG site and tube care in accordance with the individual’s current care plan, the instructions applicable to the specific gastrostomy device and advice provided by the responsible healthcare team.

Hand hygiene must be performed before and after PEG care.

The gastrostomy site must be observed at the frequency specified in the care plan and staff must identify and report signs including:

• redness or spreading inflammation;
• swelling;
• increased warmth;
• pain or tenderness;
• purulent or unusual discharge;
• offensive odour;
• bleeding;
• leakage of gastric contents or feed;
• deterioration or breakdown of surrounding skin;
• excessive granulation tissue;
• movement or change in the external position of the tube; and
• fever or other signs that the individual is systemically unwell.

The gastrostomy site must be cleaned and dried using the method specified in the individual’s care plan. Products, dressings, creams or powders must not be routinely applied unless their use is clinically indicated or specified in the individual’s care plan.

The external fixation device must be maintained at the position advised for the individual. Staff must not tighten, loosen or reposition it unless this forms part of the individual’s prescribed gastrostomy-care procedure and the staff member has been trained and assessed as competent to do so.

Rotation and/or advancement must only be undertaken where this is appropriate for the individual’s specific type of gastrostomy tube and is included in their current care plan or clinical instructions.

A newly inserted PEG must not be rotated or advanced before the period specified by the inserting clinical team or applicable device guidance.

Staff must not rotate a gastrostomy tube where the person’s tube type or clinical instructions state that rotation is contraindicated.

Any resistance, pain, bleeding, unexpected movement or inability to carry out prescribed rotation or advancement must be reported promptly to the appropriate healthcare professional. Staff must not use force.

5.2 Infection Prevention, Equipment and Prevention of Blockage

Standard infection prevention and control precautions must be followed whenever staff handle an enteral feeding system.

Equipment must be used, cleaned, stored, changed and disposed of in accordance with the manufacturer’s instructions, the individual’s clinical instructions and the organisation’s infection prevention and control procedures.

Only equipment intended for enteral use must be connected to an enteral feeding tube.

The tube must be flushed at the times and with the type and volume of water specified in the individual’s care plan. This normally includes prescribed flushing before and after feeds and medicines and between individual medicines where applicable.

Staff must not automatically use sterile water for every individual. The required water must be identified in the individual’s care plan according to clinical assessment and the position and type of tube.

Staff must monitor for signs of tube blockage, including increased resistance during flushing or difficulty administering feed, water or medicines.

Force must never be used to overcome resistance in a gastrostomy tube.

Any suspected infection, significant leakage, deterioration of the site, recurrent blockage or concern about equipment integrity must be reported and escalated in accordance with the individual’s care plan.

6. Recognising and Managing Complications

6.1 Identifying PEG Tube Complications

Staff must be trained to identify and respond to the following complications:

• Tube blockages – Difficulty flushing or administering feed.
• Leakage around the tube site – May indicate improper tube positioning or infection.
• Infection or irritation – Redness, swelling, pus, pain, or fever.
• Aspiration risk – Coughing or difficulty breathing after feeding.
• Dislodged or misplaced tube – Requires urgent medical attention.

6.2 Responding to PEG Emergencies

Staff must follow the individual’s emergency PEG plan and act promptly when a complication is identified.

Suspected blocked tube

If the PEG appears blocked:

• stop the feed or medicine administration;
• check for obvious external causes such as a closed clamp, kink or incorrectly positioned connector;
• only attempt flushing using the method and fluid permitted by the individual’s care plan or current clinical instructions;
• use gentle pressure only;
• never use excessive force;
• do not insert objects into the tube;
• do not use carbonated drinks, fruit juice or another substance to unblock the tube unless an appropriately qualified healthcare professional has specifically instructed this for the individual; and
• if the blockage does not resolve promptly using the authorised method, stop and obtain advice from the appropriate healthcare professional.

Suspected displacement or incorrect position

If the tube position appears to have changed, the external tube marking has altered unexpectedly, the tube has been pulled, there is unusual movement, significant leakage, pain, new bleeding, abdominal swelling or any other reason to suspect displacement:

• stop all feed, water and medicines through the tube;
• do not use the tube until it has been assessed and confirmed as safe to use;
• seek urgent advice in accordance with the individual’s emergency plan; and
• call 999 where the individual has symptoms indicating a medical emergency.

Following replacement of a dislodged gastrostomy tube, staff must not restart feed, water or medicines until the tube has been confirmed as safe to use in accordance with the responsible healthcare team’s instructions.

Obtaining gastric aspirate or a pH result alone must not be treated as confirmation that a newly replaced gastrostomy tube has been correctly positioned.

Tube falls out

If a gastrostomy tube falls out:

• stop all attempts to administer feed, water or medicines;
• note the time at which the tube was discovered to be out and, where known, approximately when it became dislodged;
• protect the site using an appropriate clean dressing if required;
• follow the individual’s emergency care plan immediately because a gastrostomy tract can begin to close;
• obtain urgent clinical assistance; and
• call 999 where indicated by the individual’s condition or emergency plan.

Support workers must not attempt to replace or reinsert a gastrostomy tube unless there is an explicit clinically authorised procedure for that individual and the worker has received specific training and has been formally assessed as competent to perform the procedure.

Suspected infection

Where infection is suspected:

• document the signs and symptoms observed;
• follow the escalation instructions in the individual’s care plan;
• seek advice from the GP, community nurse, enteral feeding team or other appropriate healthcare professional; and
• administer prescribed treatment only in accordance with the person’s medication instructions and MAR.

Aspiration or respiratory emergency

If the individual coughs significantly, chokes, vomits, develops breathing difficulties, becomes cyanosed, becomes acutely drowsy or shows other signs of possible aspiration or respiratory compromise:

• stop the feed immediately;
• follow the individual’s emergency plan;
• provide emergency assistance within the staff member’s training and competence; and
• call 999 where the individual has breathing difficulty, suspected significant aspiration or another medical emergency.

All PEG-related emergencies, actions taken, advice received and subsequent outcomes must be recorded and reported in accordance with the organisation’s incident reporting procedures.

7. Risk Assessment and Safety Measures

An individual PEG and enteral feeding risk assessment must be completed before staff provide PEG support.

The assessment must be individualised and must consider, where applicable:

• aspiration and choking;
• the individual’s required position during and after feeding;
• feed tolerance;
• nutritional and hydration requirements;
• dehydration and overhydration;
• fluid restriction;
• gastrostomy site infection;
• skin damage;
• tube blockage;
• tube damage;
• accidental pulling or displacement;
• accidental tube removal;
• risks associated with the individual’s behaviour, mobility or activities;
• the external position of the tube and how changes will be identified;
• safe administration of medicines;
• medicine-feed interactions;
• allergies and intolerances;
• safe use of pumps, giving sets, enteral syringes and other equipment;
• infection prevention and control;
• storage and handling of feed and equipment;
• availability of appropriate supplies;
• communication needs;
• consent and mental capacity;
• any restrictions required to provide care safely;
• staff numbers and competencies required;
• arrangements for care away from the individual’s home;
• shared-care arrangements with community nursing, dietetic, pharmacy, GP, enteral feeding and other relevant services; and
• emergency arrangements for blockage, displacement, accidental removal, aspiration, bleeding, infection and other identified complications.

Reasonably practicable measures must be put in place to reduce identified risks while maintaining the individual’s independence, dignity, rights and choices.

Risk assessments must be reviewed:

• at the planned review date;
• when the individual’s condition or needs change;
• when the feeding or hydration regimen changes;
• when medicines administered through the tube change significantly;
• following replacement or a change in the type of gastrostomy device;
• following a PEG-related incident, near miss or complication;
• following relevant healthcare advice; and
• whenever staff identify that existing controls may no longer adequately manage the risk.

Where responsibility for PEG care is shared with another health or social care provider, relevant information must be shared lawfully and promptly and responsibilities must be clearly documented so that there are no unsafe gaps in care.

8. Staff Training and Competency

Staff must only undertake PEG care that falls within their role and for which they have received appropriate training, instruction and competency assessment.

No member of staff may provide PEG feeding, PEG medication administration or another PEG-related clinical support procedure independently until they have demonstrated the knowledge and practical skills required for the individual’s procedure and have been assessed as competent by an appropriately skilled person.

PEG training and competency assessment must cover the activities staff are expected to perform and must include, where applicable:

• understanding the individual’s gastrostomy device and care plan;
• safe administration of enteral feed and water;
• safe use of feeding pumps and other equipment;
• appropriate positioning and aspiration prevention;
• prescribed checking of the tube and external position before use;
• safe flushing techniques;
• administration of medicines through an enteral tube;
• infection prevention and PEG site care;
• appropriate tube rotation and/or advancement where applicable;
• recognising infection, blockage, displacement and other complications;
• action following accidental tube removal;
• recognition of aspiration and other medical emergencies;
• consent and application of the Mental Capacity Act 2005;
• record keeping and incident reporting; and
• when to stop the procedure and obtain healthcare advice.

Staff must receive supervised practice until they have demonstrated the required level of competence.

Competency must be reassessed at least annually under this policy and sooner where:

• a staff member has not performed the procedure for a significant period;
• an incident or concern calls their competence into question;
• equipment or procedures change;
• the individual’s needs or gastrostomy device change;
• the staff member identifies that they require further support; or
• a manager, trainer or healthcare professional identifies a need for reassessment.

If a staff member has not demonstrated or maintained competence, they must not undertake the relevant PEG procedure independently until additional training, supervision and reassessment have been completed.

Training and competency records must be maintained and available for monitoring and audit.

In addition to PEG-specific competency requirements, all staff working for the purpose of the organisation’s regulated activities must receive training in learning disability and autism that is appropriate to their role, in accordance with the statutory requirements applicable to CQC-registered providers and the current statutory Code of Practice.

The Registered Manager must ensure that training requirements are monitored and that action is taken promptly where mandatory or role-specific training or competency has expired or is incomplete.

9. Record-Keeping and Documentation

Records relating to PEG care must be accurate, complete, legible, secure, up to date and contemporaneous.

Staff must record the care that they provide at the time of the intervention or as soon as reasonably practicable afterwards.

Records must include, where applicable:

• the date and time of PEG care;
• site observations and any abnormalities identified;
• the expected and observed external tube position or centimetre marking where this forms part of the individual’s care plan;
• PEG site cleaning and other prescribed site care;
• prescribed rotation and/or advancement where undertaken;
• feed administered, including type, amount, time and method;
• water and other prescribed fluids administered;
• flushes given;
• the individual’s position during and following feeding where this requires monitoring;
• the individual’s tolerance of feed and fluids;
• medicines administered through the tube, documented on the MAR;
• omitted or refused feeds, fluids or medicines and the reason;
• signs of nausea, vomiting, aspiration, pain, leakage, bleeding, infection, blockage, displacement or other complications;
• changes in the individual’s condition;
• consent where this needs to be specifically recorded;
• relevant Mental Capacity Act assessments and best-interests decisions;
• actions taken in response to concerns;
• healthcare advice sought and received, including the name or role of the professional where appropriate;
• changes made to the care plan or clinical instructions following professional advice;
• accidents, incidents and near misses; and
• escalation, emergency intervention and outcomes.

Staff must not falsify, retrospectively alter without appropriate identification, omit relevant information from or create misleading entries in PEG-care records.

Any correction or amendment must preserve an appropriate audit trail in accordance with the organisation’s record-keeping procedures.

Where a healthcare professional provides new instructions relating to feed, hydration, medicines, tube management or emergency care, these must be recorded and communicated promptly to relevant staff and the individual’s care plan must be updated without undue delay.

Records must be accessible to authorised staff when required for safe delivery of care while remaining protected against unauthorised access, alteration, loss or disclosure.

PEG-care records must be stored, retained and securely destroyed in accordance with applicable data protection legislation, the organisation’s confidentiality and records-management arrangements and SL34 – Confidentiality and Data Protection (GDPR) Policy.

10. Monitoring and Continuous Improvement

• Quarterly audits will ensure compliance with PEG management protocols.
• Feedback from individuals receiving PEG care and their families will be used to improve care quality.
• Lessons learned from incidents or near misses will be incorporated into training and policy updates.

11. Policy Review

This policy will be reviewed annually or sooner if required due to:

• Updates in NICE or CQC guidelines.
• Changes in best practice for PEG management.
• Feedback from staff, individuals receiving support, or healthcare professionals.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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