Medication Management Audit - Care Homes

Q1 | Unanswered

Is there a current medication management policy, based on recognised Scottish legislation and professional guidance, which clearly sets out how the service orders, receives, stores, administers, records, reviews and disposes of medicines?

Q2 | Unanswered

Does each person's personal plan record their medication needs, allergies, preferences, communication needs, known risks and the level of support they have agreed to receive?

Q3 | Unanswered

Are people supported to make informed choices about their medicines and to ask for advice from their GP, community pharmacist or other appropriate healthcare professional?

Q4 | Unanswered

Where a person manages their own medicines, is their choice supported through an individual risk assessment, appropriate secure storage, agreed monitoring and regular review?

Q5 | Unanswered

Where a person may lack capacity to decide about medication support, are decisions made and recorded in line with the Adults with Incapacity (Scotland) Act 2000, involving the person and relevant representatives or professionals as appropriate?

Q6 | Unanswered

Where covert medication is considered, is there clear evidence of an individual assessment, lawful authority, best-interest decision-making, prescriber and pharmacist input, a written plan and regular review?

Q7 | Unanswered

Do staff check the right person, medicine, dose, route, time and any relevant instructions before administration, and seek advice rather than making assumptions when information is unclear?

Q8 | Unanswered

Are medication administration records complete, contemporaneous and legible, including clear reasons and follow-up where a dose is omitted, delayed, refused, unavailable or not administered?

Q9 | Unanswered

Are prescribed medicines ordered in good time, received safely, checked against the prescription or delivery information and available without avoidable interruption?

Q10 | Unanswered

Are medicines stored securely, accessibly for authorised staff and in line with manufacturer requirements, with checks for expiry dates, cleanliness and protection from damage or unauthorised access?

Q11 | Unanswered

Are medicine fridge temperatures monitored, acted on promptly when outside the required range, and recorded with evidence of advice or corrective action?

Q12 | Unanswered

Are controlled drugs stored, administered, witnessed where required, recorded and reconciled in line with current legal requirements and the service's controlled-drugs procedures?

Q13 | Unanswered

Do stock checks for a sample of medicines, including controlled drugs where held, match administration records and show prompt investigation of discrepancies?

Q14 | Unanswered

Are PRN (when required) medicines supported by person-specific protocols that explain the indication, dose limits, minimum interval, alternatives, monitoring and when to seek clinical advice?

Q15 | Unanswered

Where homely remedies are used, is there an approved service process with individual suitability checks, safe administration guidance, recording and appropriate review?

Q16 | Unanswered

Are high-risk, time-critical, anticoagulant, insulin, opioid, patch, eye-drop, inhaled or other specialist medicines supported through clear individual instructions and competent practice?

Q17 | Unanswered

Are creams, topical medicines and transdermal patches administered to the correct site and frequency, with body maps or other directions used where needed?

Q18 | Unanswered

When prescriptions are changed, a person returns from hospital, or is transferred between services, are medicines reconciled promptly and changes communicated to the person, staff, prescriber and pharmacy as needed?

Q19 | Unanswered

Are medicines for people who are away from the service, admitted to hospital or approaching end of life managed safely, with continuity arrangements and documentation appropriate to the circumstances?

Q20 | Unanswered

Are discontinued, expired, unwanted or returned medicines clearly segregated, recorded and disposed of safely through an authorised route, with records retained as required?

Q21 | Unanswered

Are medication errors, omissions, near misses, adverse effects and missing medicines acted on immediately to protect the person, recorded accurately, escalated to the appropriate people and reported externally where required?

Q22 | Unanswered

Do investigations of medicines incidents consider contributory factors, the person's wellbeing, communication with families or representatives where appropriate, learning and actions to reduce recurrence?

Q23 | Unanswered

Are staff who handle medicines trained, assessed as competent before working independently, supervised and reassessed when practice, role, guidance or identified risks require it?

Q24 | Unanswered

Do handovers and daily communication reliably identify medication changes, refusals, shortages, side effects, monitoring needs and outstanding actions?

Q25 | Unanswered

Are people monitored for the intended effect, side effects, deterioration, pain or other medication-related concerns, with timely escalation to the prescriber or relevant healthcare professional?

Q26 | Unanswered

Are regular medicines audits based on observation and record review, including administration practice, storage, stock, controlled drugs, records and individual outcomes rather than paperwork alone?

Q27 | Unanswered

Do medication audit findings, incidents, complaints and professional advice result in named actions, completion checks and evidence that improvements have made medication support safer for people?

Q28 | Unanswered

Can the service demonstrate that medication management protects each person's dignity, privacy, rights, independence and wellbeing while meeting their individual health needs?