Medication Audit - Domiciliary Care

Evidence to check

• • Staff can explain practical medication responsibilities, not just refer to the policy
• • Medication policy is current and specific to domiciliary care
• • Staff know where to find medication guidance if unsure
• • Policy reflects prompting, assisting, administering and self-administration

Evidence to check

• • Medication training records
• • Medication competency assessments
• • Observed practice records or spot checks
• • No staff supporting medicines before competency sign-off

Evidence to check

• • Medication risk assessments for sampled service users
• • Assessment reflects cognition, dexterity, vision, memory and understanding
• • Home storage risks considered
• • Risk assessment updated after changes, incidents or concerns

Evidence to check

• • Medication support plan clearly states staff role
• • Staff can explain the level of support required
• • MAR records match the agreed level of support
• • Family or informal carer responsibilities are clearly recorded where relevant

Evidence to check

• • Staff scenario-based responses
• • Care notes show correct terminology
• • Staff do not administer where only prompting is agreed
• • Support plans clearly define what staff can and cannot do

Evidence to check

• • Care notes showing concerns about missed doses or confusion
• • Medication risk assessment reviewed after deterioration
• • Family, GP, pharmacist or office informed where needed
• • Support level changed where self-management is no longer safe

Evidence to check

• • MAR charts for sampled service users
• • Entries completed at each relevant visit
• • No unexplained gaps, late entries or retrospective signing
• • Correct dose, time, route, code and staff signature recorded

Evidence to check

• • MAR storage checked during visit or audit
• • Records not left visible to unauthorised visitors
• • Staff know where records are kept
• • Records are available when staff need to complete them

Evidence to check

• • Handwritten MAR entries sampled
• • Two signatures or checking process where required by policy
• • Prescriber/pharmacy instruction available
• • No unclear, incomplete or unauthorised handwritten entries

Evidence to check

• • Observation of medication support where possible
• • Staff check right person, medicine, dose, time and route
• • MAR and medication label are checked before administration
• • No shortcuts, assumptions or administration from memory

Evidence to check

• • Staff scenario-based responses
• • Medication incident and near miss records
• • Care notes showing escalation of refusals or missed doses
• • Staff know out-of-hours reporting route

Evidence to check

• • Medication incident reports
• • Investigation records and root cause analysis
• • Immediate safety actions recorded
• • Learning shared through supervision, meetings or briefings

Evidence to check

• • MAR refusal or omission codes used correctly
• • Care notes explain what happened
• • Office, family, GP or pharmacist informed where needed
• • Repeated refusals or missed doses trigger review

Evidence to check

• • PRN protocols for sampled service users
• • Reason for PRN administration recorded
• • Effectiveness review documented after administration
• • No routine use of PRN without clear rationale

Evidence to check

• • Time-critical medicines highlighted in support plans
• • Visit schedules match required administration times
• • Records of escalation when visits are delayed
• • Examples include Parkinson's medicines, insulin, epilepsy medicines or anticoagulants

Evidence to check

• • Allergy information on MAR and care plan
• • No contradictions between records
• • Staff can explain allergy checks
• • Known allergies or sensitivities reflected in medication guidance

Evidence to check

• • Delivery or collection records
• • Medication receipt records where used
• • MAR updated after medicine changes or new supply
• • Discrepancies investigated and recorded

Evidence to check

• • Current prescription list or pharmacy printout
• • MAR reflects current prescribed medicines
• • Changes communicated to staff promptly
• • Old or discontinued medicines clearly removed from active records

Evidence to check

• • Mental capacity assessment for medication decision
• • Best-interest decision record
• • GP/pharmacist involvement
• • Clear care plan guidance on how covert medication must be given and reviewed

Evidence to check

• • Medication storage risk assessment
• • Secure storage where risk requires it
• • Medicines not left accessible to people at risk, children or visitors
• • Storage arrangements respect the person's rights and preferences where safe

Evidence to check

• • Records of returned or disposed medicines
• • Expired or discontinued medicines not left in active use
• • Consent or family involvement where relevant
• • Pharmacy or prescriber contacted where needed

Evidence to check

• • Care notes showing side effects or concerns
• • Escalation to office, GP, pharmacist or emergency services
• • Staff can describe signs requiring urgent action
• • Follow-up actions and outcomes recorded

Evidence to check

• • Topical MAR charts or body maps where used
• • Patch site rotation records
• • Instructions for eye drops, inhalers or creams
• • Staff competency for specialist administration tasks where required

Evidence to check

• • Observation of medication support where possible
• • Staff clean hands before and after medication tasks
• • Gloves or PPE used appropriately, not unnecessarily
• • No contamination of medicines, MAR charts or equipment

Evidence to check

• • Discrepancy records
• • Care notes or office logs showing escalation
• • Contact with pharmacy, GP or family where needed
• • Resolution and prevention actions documented

Evidence to check

• • Controlled drug guidance in care plan
• • Records of administration and stock checks where applicable
• • Staff understand legal and organisational requirements
• • Discrepancies or concerns escalated immediately

Evidence to check

• • Staff scenario-based responses
• • Escalation flowchart or guidance available
• • Records showing concerns escalated appropriately
• • Out-of-hours contact arrangements understood

Evidence to check

• • Care plan records family or carer role
• • Staff responsibilities are clearly separated from family responsibilities
• • Communication records about changes or concerns
• • No evidence of double-dosing, missed doses or unclear accountability

Evidence to check

• • Visit schedules and call durations
• • Staff feedback about rushing or time pressure
• • MAR completion at the visit
• • Late or missed calls reviewed for medication impact

Evidence to check

• • Medication audit records
• • Audit includes MAR review, care plan review and staff feedback
• • Actions identified and followed up
• • Repeated issues escalated through governance

Evidence to check

• • Spot check records
• • Supervision notes discussing medication practice
• • Medication competency observations
• • Actions taken where practice concerns are identified

Evidence to check

• • Care plan review records
• • Medication updates after hospital discharge or GP review
• • Changes communicated to staff
• • MAR, care plan and prescription information kept consistent

Evidence to check

• • eMAR records
• • Audit trail showing timely entries
• • Staff do not share logins or bypass the system
• • Alerts, missed entries or errors reviewed by management

Evidence to check

• • Care plan records the person's understanding and preferred level of involvement
• • Staff explain medication support in a way the person understands
• • Accessible information used where needed
• • Person's questions or concerns are recorded and followed up

Evidence to check

• • Records of OTC medicines, supplements or homely remedies
• • GP/pharmacist advice where required
• • Risk assessment considers interactions and allergies
• • Staff know whether they may prompt, assist or administer these items

Evidence to check

• • Refresher training records
• • Competency reassessments
• • Training updated after incidents or policy changes
• • Staff knowledge checked through supervision or spot checks

Evidence to check

• • Out-of-hours escalation procedure
• • Staff know who to contact urgently
• • Records of out-of-hours medication calls or incidents
• • No evidence of staff making unsafe medication decisions alone

Evidence to check

• • Staff understand safeguarding links to medication practice
• • Medication incidents reviewed for safeguarding threshold
• • Safeguarding referrals made where required
• • Rationale recorded where safeguarding referral was not made

Evidence to check

• • Lessons learned records
• • Team meeting or briefing notes
• • Changes made after incidents
• • Follow-up checks showing improvement was sustained

Evidence to check

• • Compare MAR charts with care notes and support plans
• • Staff describe the same support level as recorded
• • Contradictions corrected promptly
• • Office review of mismatched records

Evidence to check

• • Discharge summaries or GP medication change records
• • Updated MAR and support plan
• • Communication to care staff
• • No duplicated, omitted or discontinued medicines left active

Evidence to check

• • Late or missed visit logs
• • Medication impact considered in incident review
• • Contact with office, family, GP or emergency services where needed
• • Scheduling changes made to prevent recurrence