Medication Audit - Care Homes

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