Medication Audit - Care Homes

Evidence to check

• • Check locked cupboards, trolleys, rooms and medicine fridges during and after medication rounds.
• • Confirm medicines are not left unattended on worktops, trolleys, trays or in resident areas.
• • Check that internal and external medicines are separated and labelled clearly.
• • Check access arrangements and whether only authorised competent staff can access medicines.
• • Confirm storage arrangements match the medicine's requirements, including refrigeration, controlled drugs and topical medicines.

Evidence to check

• • Review daily room and fridge temperature logs for missing entries, repeated identical entries or retrospective completion.
• • Check whether out-of-range readings have a recorded action, escalation and outcome.
• • Confirm staff know the acceptable temperature ranges and what to do if readings are outside range.
• • Check thermometer calibration, fridge maintenance records or replacement actions where relevant.
• • Compare records with staff explanations to confirm the process is actually followed in practice.

Evidence to check

• • Compare MAR charts with current prescriptions, stock balances and administration instructions.
• • Check for gaps, late signatures, missing codes, overwriting, unclear amendments or retrospective entries.
• • Cross-check care notes where doses were refused, delayed, omitted or administered differently.
• • Ask staff to explain selected MAR entries and confirm their explanation matches the record.
• • Where possible, compare observed practice during a medication round with the MAR documentation.

Evidence to check

• • Review recent MAR audits, daily checks or manager spot checks.
• • Check whether gaps are investigated rather than simply signed later.
• • Look for recurring patterns involving the same resident, medicine, staff member, round or time of day.
• • Check whether actions are assigned, dated and followed up.
• • Confirm learning or corrective action has been shared with relevant staff.

Evidence to check

• • Check medication training certificates and dates for permanent, bank and agency staff where applicable.
• • Review practical competency assessments and evidence of observed medication rounds.
• • Check supervision notes for medication practice discussions, concerns or reassessment.
• • Confirm staff have been reassessed after errors, concerns, absence or changes in responsibility.
• • Ask staff practical medication questions linked to residents they support.

Evidence to check

• • Review recent refusals, omissions, delays and medication errors on MARs and incident records.
• • Check whether staff documented the reason, immediate action, resident wellbeing checks and escalation.
• • Ask staff scenario-based questions about refusals, missed doses, wrong doses and late doses.
• • Check evidence of GP, pharmacist, senior staff, family or safeguarding escalation where required.
• • Confirm follow-up monitoring is recorded in daily notes or clinical records.

Evidence to check

• • Review incident forms, investigation notes and management reviews.
• • Check whether root causes were explored, not just attributed to 'staff error'.
• • Look for evidence of resident safety checks, medical advice, family communication and duty of candour where relevant.
• • Check team meeting notes, supervision records or learning briefings after incidents.
• • Confirm whether changes were implemented and reviewed for effectiveness.

Evidence to check

• • Check PRN protocols are present, person-specific and available to staff administering the medicine.
• • Review MARs and care notes for the reason PRN medicine was given.
• • Check whether the outcome/effectiveness was recorded after administration.
• • Ask staff when they would give or withhold selected PRN medicines for current residents.
• • Look for repeated PRN use without review or escalation.

Evidence to check

• • Review receipt records, delivery notes and stock entries for recent medicines.
• • Check whether two staff checked medicines where the provider's procedure requires it.
• • Confirm MAR charts were updated accurately and promptly following receipt.
• • Check whether medicines were available for the next scheduled dose.
• • Ask staff how they deal with missing, incorrect or unclear medicines on delivery.

Evidence to check

• • Check disposal/returns records against physical stock and MAR changes.
• • Look for expired medicines, discontinued medicines or duplicate stock still available for use.
• • Confirm controlled drug returns are recorded in line with the provider's procedure.
• • Check whether returns to pharmacy are documented and signed.
• • Ask staff how they prevent discontinued medicines from being administered in error.

Evidence to check

• • Review the last medication audits and check whether they include observation, staff questioning and record sampling.
• • Check whether audits identify practice issues such as interruptions, unsafe shortcuts or inconsistent recording.
• • Confirm audit samples cover different residents, medicines, staff and times of day.
• • Look for evidence that findings are discussed with staff and managers.
• • Check whether audit results are compared over time to identify trends.

Evidence to check

• • Review action plans linked to previous medication audits.
• • Check whether actions have owners, target dates and completion evidence.
• • Compare previous and current audit findings for repeated issues.
• • Look for follow-up checks confirming whether the action worked in practice.
• • Confirm staff can describe changes made because of audit findings.

Evidence to check

• • Check medication review dates and records for selected residents.
• • Look for review outcomes, changed medicines, stopped medicines or monitoring requirements.
• • Confirm MAR charts, care plans and staff handovers reflect the review outcome.
• • Check whether residents with high-risk medicines, polypharmacy or repeated PRN use are prioritised for review.
• • Ask staff how they know when a resident needs a medication review.

Evidence to check

• • Review care plans and consent records for involvement in medication decisions.
• • Check records of discussions with residents, relatives, advocates or representatives.
• • Ask residents or representatives whether medicines are explained and concerns are listened to.
• • Look for evidence that preferences such as timing, format, swallowing needs or cultural considerations are recorded.
• • Check whether concerns about effectiveness or side effects were followed up.

Evidence to check

• • Observe or review a controlled drug administration where possible.
• • Check the controlled drugs register against MAR entries and physical stock.
• • Confirm two signatures are recorded where required and entries are completed at the time of administration.
• • Look for corrections, gaps, unclear entries or retrospective recording.
• • Ask staff to explain the controlled drugs process using a current resident example.

Evidence to check

• • Check controlled drug cupboard security and access arrangements.
• • Compare physical stock with the controlled drug register and MAR chart.
• • Review frequency and quality of controlled drug stock checks.
• • Check how discrepancies were investigated and escalated.
• • Confirm discontinued or returned controlled drugs are recorded correctly.

Evidence to check

• • Review self-administration risk assessments and review dates.
• • Check whether the person has secure storage and can access medicines safely.
• • Confirm staff monitoring checks are completed and meaningful.
• • Ask staff how they respond if the resident's ability changes or doses are missed.
• • Check whether the resident's views and preferences are reflected in the arrangement.

Evidence to check

• • Review the homely remedies policy, approved list and authorisation arrangements.
• • Check whether homely remedies are recorded on MARs or administration records.
• • Confirm staff check allergies, contraindications and current medicines before use.
• • Look for evidence of outcome monitoring and escalation if symptoms persist.
• • Ask staff when homely remedies must not be given.

Evidence to check

• • Check allergy information on MAR charts, care plans and electronic records.
• • Look for contradictions or missing allergy information across records.
• • Observe whether staff check allergy status during administration.
• • Ask staff how they verify allergy information for a resident they support.
• • Check whether new or suspected allergies are escalated and recorded promptly.

Evidence to check

• • Observe staff completing identity, medicine, dose, time and route checks during a medication round.
• • Check use of photographs, MAR charts and resident confirmation where appropriate.
• • Ask staff to talk through the five rights using a real resident example.
• • Look for shortcuts such as pre-pouring, relying on memory or signing before administration.
• • Confirm staff pause and seek advice where anything does not match.

Evidence to check

• • Review medication incidents, safeguarding logs and CQC notification records.
• • Check whether serious errors, harm, repeated concerns or neglect indicators were escalated appropriately.
• • Look for evidence of referral to safeguarding, CQC, GP, pharmacist or commissioning teams where relevant.
• • Confirm the rationale is documented where no external referral was made.
• • Check timeliness and completeness of notifications.

Evidence to check

• • Review training records for staff who administer or support with medicines.
• • Check whether training includes relevant topics such as PRN, controlled drugs, covert medicines, time-critical medicines and error response.
• • Compare training completion with competency assessments and observed practice.
• • Check whether agency or new staff have been assessed before administering medicines.
• • Look for refresher training or targeted learning following incidents or audit findings.

Evidence to check

• • Review handover notes, communication books and electronic shift records.
• • Check whether medication changes, refusals, missed doses or low stock are carried forward until resolved.
• • Ask incoming staff what current medication issues they need to follow up.
• • Look for gaps between MAR records, daily notes and handover communication.
• • Confirm actions are completed rather than repeatedly passed between shifts.

Evidence to check

• • Review topical MARs, body maps and care plans for current instructions.
• • Check whether application sites, frequency and rotation instructions are clear.
• • Look for missing signatures or vague records such as 'cream applied' without site detail.
• • Observe practice or ask staff to explain how they apply selected topical medicines.
• • Check whether patches are dated, sited correctly and old patches removed where applicable.

Evidence to check

• • Review records for recent hospital admissions, appointments, home visits or absences.
• • Check whether medicines sent with the resident were documented and signed out.
• • Confirm medicines were reconciled on return or after discharge.
• • Check communication with hospital, GP, pharmacy, family or transport staff where relevant.
• • Look for missed, duplicated or delayed doses linked to absence or transfer.

Evidence to check

• • Inspect medication trolleys during and outside medication rounds.
• • Check cleanliness, organisation, lock use and whether medicines are left unattended.
• • Review trolley check records and cleaning schedules.
• • Look for loose tablets, expired items, confidential records left visible or mixed resident medicines.
• • Observe whether the trolley is positioned and used safely during administration.

Evidence to check

• • Review recent hospital admissions, falls, deterioration, behavioural changes and incident records.
• • Check whether medication causes or side effects were considered as part of the review.
• • Look for GP/pharmacist advice, medication review or monitoring after concerns.
• • Check whether family or representative communication was recorded where relevant.
• • Confirm learning and preventative actions were recorded and followed up.

Evidence to check

• • Review MAR audits, daily MAR checks and medication incident trends.
• • Look for repeated issues by staff member, resident, medicine, shift, round or unit.
• • Check whether causes such as staffing, interruptions, stock delays or unclear instructions were explored.
• • Confirm corrective actions were taken and reviewed for effectiveness.
• • Check whether repeated issues were escalated to management.

Evidence to check

• • Ask staff scenario questions linked to medicines currently used in the service.
• • Check staff awareness of high-risk medicines and common side effects.
• • Review records where side effects or adverse reactions were suspected or reported.
• • Check whether concerns were escalated to GP, pharmacist or senior staff.
• • Confirm staff know how to monitor and document resident changes after medication concerns.

Evidence to check

• • Review mental capacity assessments and best-interest decision records.
• • Check involvement of prescriber, pharmacist, family or representatives as appropriate.
• • Confirm the MAR and care plan give clear instructions on how medicines are administered covertly.
• • Look for review dates and evidence that covert administration remains necessary.
• • Ask staff how covert medicines are given safely and discreetly for the specific resident.

Evidence to check

• • Ask a sample of staff about recent medication learning in the service.
• • Compare staff accounts with incident records, meeting minutes or supervision notes.
• • Check whether the learning led to a practical change, not just a reminder to be careful.
• • Look for consistency across staff responses.
• • Confirm changes were embedded through follow-up checks or audits.

Evidence to check

• • Review complaints, compliments, feedback records and daily notes for medication concerns.
• • Check whether concerns about effectiveness, side effects, timing or communication were investigated.
• • Look for responses to residents or families and evidence of follow-up.
• • Confirm medication concerns are linked to reviews, GP/pharmacy advice or care plan updates where needed.
• • Ask residents or relatives whether they feel listened to about medicines.

Evidence to check

• • Complete or review physical stock counts for selected medicines.
• • Compare expected balances with MAR entries, receipt records and returns.
• • Check whether low stock, overstocking or unexplained discrepancies are identified promptly.
• • Review actions taken for stock discrepancies or ordering problems.
• • Ask staff how they prevent residents running out of medicines.

Evidence to check

• • Review induction records for new staff who administer or support medicines.
• • Check evidence of shadowing, observed rounds and practical competency sign-off.
• • Confirm new staff did not administer medicines unsupervised before assessment.
• • Review supervision notes for early practice concerns or support needs.
• • Ask recently inducted staff how they were assessed before administering medicines.

Evidence to check

• • Review team meeting minutes, debrief notes, supervision records and training logs.
• • Check whether discussions used real incidents or realistic scenarios.
• • Ask staff what they learned and what changed in practice.
• • Look for evidence that learning was shared with all relevant shifts and staff groups.
• • Confirm follow-up checks tested whether learning was embedded.

Evidence to check

• • Review examples of prescription queries, medication changes or unclear instructions.
• • Check records of calls/emails to GP, pharmacy, prescriber or senior staff.
• • Ask staff what they would do if a prescription appears unsafe or unclear.
• • Look for evidence that medicines were withheld or escalated safely pending clarification where appropriate.
• • Confirm advice received was documented and reflected in MARs and care plans.

Evidence to check

• • Identify residents on time-critical medicines such as insulin, anticoagulants, Parkinson's medicines, epilepsy medicines or pain relief.
• • Review MAR times against prescribed or clinically required times.
• • Ask staff which medicines are time-critical and why timing matters.
• • Check escalation records for any late or missed time-critical doses.
• • Look for systems that help staff prioritise time-critical medicines during busy rounds.

Evidence to check

• • Review medication support plans for residents with swallowing difficulty, cognitive impairment, distress, sensory needs or complex routines.
• • Observe or discuss how staff support the resident in practice.
• • Check whether staff use the person's preferred approach and communication needs.
• • Look for evidence of monitoring after administration where risks are present.
• • Confirm the plan is reviewed when needs, capacity, medicines or risks change.

Evidence to check

• • Compare prescriptions, MARs, stock, hospital letters and pharmacy records for selected residents.
• • Check whether discrepancies are recorded, escalated and resolved promptly.
• • Look for clinical input where high-risk medicines are involved.
• • Confirm staff do not administer based on assumptions where records conflict.
• • Review whether resolved discrepancies led to learning or system improvement.

Evidence to check

• • Review recent discharge summaries, outpatient letters and medication changes.
• • Check whether MAR charts were updated promptly and accurately.
• • Confirm discontinued medicines were removed from active use and new medicines obtained without delay.
• • Check communication to staff through handover, notes or alerts.
• • Look for duplicated, omitted or conflicting medicines after discharge or review.