Medication Audit - Care Homes
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- Q1: Are all medicines stored securely in a locked cupboard or fridge according to their requirements?
- Q2: Is fridge and room temperature monitored daily for medicine storage areas?
- Q3: Are medication administration records (MARs) completed clearly and accurately after each administration?
- Q4: Are MAR charts reviewed regularly for missing signatures or gaps?
- Q5: Are staff administering medicines trained, assessed, and deemed competent?
- Q6: Do staff know what to do in the event of a medication error or refusal?
- Q7: Are medication errors recorded, investigated, and shared with staff for learning?
- Q8: Are PRN (as-needed) medicines administered according to a written protocol and reviewed regularly?
- Q9: Is there a clear procedure for receiving, checking, and recording new medicines?
- Q10: Are discontinued or expired medicines disposed of according to current regulations?
- Q11: Are regular audits of medication systems carried out and documented?
- Q12: Are any issues identified in audits followed up with clear action plans?
- Q13: Do residents have access to regular medication reviews by a pharmacist or prescriber?
- Q14: Are residents (or their representatives) involved in decisions about their medicines?
- Q15: Are staff aware of and follow best practice when administering controlled drugs?
- Q16: Are controlled drugs stored and recorded in a separate controlled drugs register?
- Q17: Is there a policy for residents who self-administer, with appropriate risk assessments?
- Q18: Are homely remedies used safely, with appropriate GP authorisation where needed?
- Q19: Is allergy information clearly recorded and checked before giving medicines?
- Q20: Do staff always check the five rights: right person, right medicine, right dose, right time, right route?
- Q21: Are medicine incidents reported to the CQC or safeguarding where required?
- Q22: Are medicine-related training records kept and up to date for all relevant staff?
- Q23: Are handovers between shifts used to discuss medicine issues or follow-ups?
- Q24: Are topical medicines (creams, patches) recorded and applied as prescribed?
- Q25: Is there a process to follow if a resident is absent or refuses medication?
- Q26: Are medication trolleys clean, locked, and checked regularly?
- Q27: Have any residents recently had a hospital admission linked to medication issues (e.g. overdose, missed dose, side effects)?
- Q28: Have any trends in missed or late doses been identified and addressed?
- Q29: Are staff confident in identifying side effects or signs of adverse drug reactions (ADRs)?
- Q30: Are covert medications used, and is there a documented best-interest decision in place with regular reviews?
- Q31: Can staff describe a recent incident involving a medication error and how it was resolved and learned from?
- Q32: Do residents or their families express concerns about medicines (effectiveness, side effects, communication)?
- Q33: Is the stock level of medicines checked regularly to prevent running out or over-ordering?
- Q34: Are new staff given a practical induction that includes supervised medication rounds before working independently?
- Q35: Have mock medication error drills or reflective learning sessions been carried out to improve response preparedness?
- Q36: Do staff understand how to escalate concerns about a GP prescription they believe may be unsafe or unclear?
- Q37: Are emergency protocols in place for time-critical medications (e.g., insulin, anticoagulants, Parkinson’s meds)?
- Q38: Is the medication support plan tailored to individual needs (e.g., swallowing difficulty, cognitive impairment)?
- Q39: Do any residents have regular discrepancies between prescribed and administered medications, and are these resolved?
- Q40: Are changes in medication following hospital discharge clearly documented and communicated to staff and GPs?