Medication Audit - Supported Living

Evidence to check

• • Medication policy includes prompting, assisting, administration, self-administration and escalation
• • Policy reflects supported living arrangements, tenancy rights and person-centred support
• • Staff can explain how the policy applies to real people they support
• • Policy is accessible, current and reviewed within the required timeframe

Evidence to check

• • Support plans clearly state the staff role for each person
• • Staff explanations match the support plan and actual practice
• • Records show whether prompts, assistance or administration were provided
• • No evidence of staff exceeding the agreed level of support without review or consent

Evidence to check

• • Current medication risk assessments for each sampled person
• • Assessment considers cognition, dexterity, understanding, mental health, misuse risks and storage
• • Review dates reflect changes in need, incidents or concerns
• • Risk assessment links clearly to the medication support plan

Evidence to check

• • Medication support plan is individualised and not generic
• • Plan includes routines, preferences, communication needs and support methods
• • Observed or described practice matches the written plan
• • Plan has been updated after changes in medicines, ability or risk

Evidence to check

• • Person's views, choices and preferences recorded
• • Evidence of involvement in reviews and decisions
• • Accessible information or explanations provided where needed
• • Records show how disagreements, refusals or concerns were handled

Evidence to check

• • Consent forms or mental capacity/best-interest records where relevant
• • Consent covers the actual level of support being provided
• • Records show consent is reviewed when circumstances change
• • Staff can explain what to do if consent is withdrawn or fluctuates

Evidence to check

• • Medication training records are current
• • Competency assessments include direct observation, not just e-learning certificates
• • Induction and supervision records reference medicine practice
• • Evidence of reassessment after incidents, errors or extended absence

Evidence to check

• • Person-specific PRN protocols are in place
• • Protocol includes signs/symptoms, dose, timing, maximum dose and escalation
• • Staff can explain the PRN protocol using the person's real circumstances
• • PRN use is reviewed where frequent, ineffective or increasing

Evidence to check

• • Reason for PRN administration recorded
• • Follow-up/effectiveness recorded after administration
• • Repeated PRN use is escalated or reviewed
• • Records match the PRN protocol and MAR/eMAR entries

Evidence to check

• • MAR/eMAR entries are complete, legible and signed in real time
• • Codes for refusal, absence, prompting or omission are used correctly
• • Entries match care notes, staff accounts and stock where relevant
• • No unexplained gaps, retrospective entries or overwriting

Evidence to check

• • Medication incident and near-miss records
• • Immediate safety checks and escalation documented
• • Investigation considers root causes, not only individual blame
• • Action taken is evidenced and followed up

Evidence to check

• • Staff responses to scenario questions
• • Escalation records to senior staff, GP, pharmacy, 111/999 or safeguarding where appropriate
• • Care notes show monitoring after refusal, error or overdose concern
• • Incident records and MAR/eMAR entries align

Evidence to check

• • Evidence of explanations given in accessible formats where needed
• • Person's understanding, preferences and questions recorded
• • Staff can describe how they support understanding without coercion
• • Records show concerns or side effects were escalated

Evidence to check

• • Allergy/sensitivity information recorded on support plans and MAR/eMAR
• • No contradictions between records
• • Staff check allergy information before administration or support
• • Unknown allergies are clearly marked and followed up where required

Evidence to check

• • Storage arrangements reflect the risk assessment and person's choices
• • Locked storage used only where needed and agreed
• • Medicines are not left accessible to others where this creates risk
• • Fridge storage, room temperature and specialist storage are managed where relevant

Evidence to check

• • Stock checks or reorder records
• • Expiry dates checked, including liquids, creams and short-dated medicines
• • Reordering is timely and documented
• • Any shortages are escalated and continuity of support is maintained

Evidence to check

• • Records of medicines returned to pharmacy or disposed of safely
• • Expired/discontinued medicines separated from active medicines
• • Stock balances updated after return/disposal
• • No expired, stopped or duplicate medicines found in active use

Evidence to check

• • Observed medication support or scenario discussion
• • Staff check MAR/eMAR, label, identity and instructions before support
• • No unsafe shortcuts or reliance on memory
• • Time-critical medicines are prioritised appropriately

Evidence to check

• • Controlled drug register or equivalent records where required
• • Stock balance matches physical stock
• • Storage arrangements are safe and proportionate
• • Staff understand witnessing, recording and escalation requirements

Evidence to check

• • Discharge summaries, GP/pharmacy communications or prescription changes
• • MAR/eMAR and support plans updated promptly
• • Staff handover records show changes were communicated
• • No duplicate, omitted or outdated medicines remain in use

Evidence to check

• • Medication review dates and outcomes
• • Actions from GP/pharmacist/prescriber reviews completed
• • Support plans and MAR/eMAR updated after reviews
• • Reviews requested where side effects, frequent PRN use or concerns are present

Evidence to check

• • Homely remedies protocol or authorisation
• • Individual suitability checks, including allergies and contraindications
• • Administration and outcome records
• • Staff understand limits, exclusions and escalation requirements

Evidence to check

• • Emergency medication plan or protocol
• • Medicines are available, in date and stored appropriately
• • Staff can explain when and how to respond
• • Escalation and post-event recording processes are clear

Evidence to check

• • Records of medicines sent or received
• • Clear handover between home, day service, respite, hospital or family setting
• • Packaging and storage during transport are safe
• • Reconciliation completed when medicines return

Evidence to check

• • Support plan covers absences, outings, day services, respite or family visits
• • Records show medicines were provided or arrangements confirmed where required
• • Staff know who is responsible during absence
• • Missed or delayed doses are recorded and escalated where needed

Evidence to check

• • Goals or plans to promote independence where appropriate
• • Risk assessments reviewed as ability changes
• • Evidence of prompts, aids, reminders or accessible information
• • Staff avoid unnecessary control where the person can self-manage safely

Evidence to check

• • Medication audit and spot-check records
• • Direct observations of practice included where possible
• • Action plans with responsible person and target dates
• • Evidence that repeated issues reduce over time

Evidence to check

• • Records of queries to GP, pharmacy, prescriber or senior staff
• • Staff scenario responses about unsafe or unclear prescriptions
• • Advice received is documented and followed
• • No evidence of staff making unsafe assumptions

Evidence to check

• • eMAR entries completed at the time support is provided
• • Individual staff logins and access controls
• • Audit trail or error reports reviewed
• • Backup process available for system outage or device failure

Evidence to check

• • Team meeting notes, supervision records or learning briefings
• • Staff can describe recent learning and what changed
• • Policy, support plan or practice changes evidenced
• • Follow-up checks confirm changes are being sustained