Title Page

  • The following forms are included as part of this policy:

    Medication Audit Form - CM16 - To audit medication processes. Frequency of completion is determined by the Registered Manager. Created by QCS

    MAR Audit - CM16 - To audit MARs. Created by QCS

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Ordering – How Medicines Are Ordered

  • Are repeat prescriptions obtained in a safe and efficient manner?

  • Are repeat prescriptions obtained in a safe and efficient manner?

  • Are there any ordering/stock problems?

  • Are medicines ordered in advance so Service Users do not miss any dosages of their medicines?

  • Are there any problems with the pharmacy or GP surgery?

  • Are records kept of medicines ordered?

  • Are records kept of medicines received?

  • Are discrepancies in the above raised with the community pharmacists and/or GP?

  • Are all medicines checked in correctly?

  • Are medicines clearly labelled by the Pharmacist?

  • If medicines are out of stock, is there a process for notifying the GP so an alternative can be prescribed if necessary?

  • Is there a process for ordering prescriptions in the middle of the ordering cycle e.g. for acute medicines or new medicines?

Storage - How Are Medicines Stored?

  • Are medicines stored safely and securely in an appropriate designated area?

  • Are storage areas clean and organised?

  • Is the medicines cupboard kept locked when not in use?

  • Are keys kept as per policy?

  • Are excessive quantities of medication being stored?

  • Are expiry dates checked monthly – both prescribed and over the counter medicines?

  • Is there a record of expiry date checks?

  • Are external medications separated from internal medications where appropriate?

  • Are there arrangements in place for Service Users who self-medicate to safely store their own medication?

  • Is stock rotated appropriately?

  • Is there any evidence of borrowing/sharing of medication?

  • Are oxygen cylinders stored upright, in a well- ventilated area away from heat and flames?

  • Are 'No Smoking' signs displayed?

Fridge Storage – How Are Fridge Items Stored?

  • Are medicines requiring refrigeration stored appropriately in a secure area?

  • Are there any items stored in the fridge that shouldn’t be stored in it?

  • Are items requiring refrigeration put away as soon as they are received?

  • Is there a process for stock rotation where the Service User has more than one bottle/box of the same medicine?

  • Are there signs that state the fridge should not be switched off?

  • Do staff know not to overstock the fridge to make sure there is space for the air to circulate?

  • Do staff know to keep the fridge door open for as short a time as possible to keep a constant temperature?

  • Do staff check that products are not frozen before administering to a Service User?

  • Does the fridge have a maximum/minimum thermometer?

  • Are all maximum/minimum fridge temperatures checked daily and the records kept?

  • Is action taken if the fridge temperatures are outside the normal range of 2-8 °C?

  • Is this action documented and retained?

  • Is the fridge cleaned and defrosted at least quarterly?

  • Do staff know what to do if the fridge breaks down?

Controlled Drugs - How Are Controlled Drugs Managed?

  • Are stock levels of Controlled Drugs appropriate?

  • Does the quantity in the CD register reflect the actual stock?

  • Is the administration of Controlled Drugs in line with current policy?

  • Are Controlled Drugs disposed of appropriately?

Disposal - How is Medication Disposed of?

  • Has medication been held for a sufficient time following a death?

  • Are any medicines destroyed in the home?

  • Is the returns record up to date?

  • Is medication for disposal separated from medicines in use?

Homely Remedies - How Are Homely Remedies Managed?

  • Does the audit trail of homely remedies tally?

  • Are all homely remedies in date?

  • Are homely remedies stored separately and securely?

  • Have any homely remedies been given for more than 2 days without contacting the GP?

Self-Managed Medication - How Are Self-Managing Service Users Supported?

  • Is there evidence that Service Users are encouraged and supported to self-manage their medication?

  • Do current Service Users who self-manage have safe, lockable storage facilities for their medication?

  • Are risk assessments completed for current Service Users who self-manage?

  • Are verbal reminders/supervision/ monitoring given (and documented) for Service Users who require them?

  • Is discreet monitoring and reassessment being carried out?

Obtaining Consent for Medication Administration?

  • Is there a process for obtaining Service Users' consent if staff administer medication?

Records - How Are Records Managed?

  • Are all administrations of medicines recorded in the appropriate place, i.e. medicines chart, Service User's notes, CD register?

  • Is the administration of medicines recorded as soon as possible after the Service User has taken the medicine?

  • Are all omissions of medicines recorded in the appropriate place, i.e. MARs, Service User's notes

  • Is there a process for verbal orders from a GP?

Medication Administration – How Are Medicines Administered?

  • Are medicines administered from original containers as received from the pharmacy, one Service User at a time?

  • Are labels printed clearly?

  • Are dosage instructions clear?

  • Have any labels been defaced or changed?

  • Are appropriate cautions and warnings clear?

  • Are all medicines labelled for individual Service Users (including medications for external use)?

  • If a monitored dosage system (MDS) is in use, are appropriate cautions and warnings clear and is there an appropriate dispensing date on the pack currently being used?

  • Is there a risk assessment for each Service User who self-medicates any of his or her medicines?

  • Are measures in place to identify Service Users to ensure that they receive the correct medicine?

  • Have all staff who are involved with prescribing and/or administering medicines read the suite of medication management policies at Aims Care Limited T/A Swallowfields Care Centre?

  • Is there a signatory list to demonstrate that staff have read and understood the policies?

  • Are allergies checked before a medicine is administered to a Service User?

  • Are medicines administered to Service Users from their original containers?

  • Is a drink offered when administering a Service User’s medicine?

  • Are medicines with short expiry dates, e.g. drops, some liquids etc. dated when they are opened?

  • Are special instructions observed when administering medicines, e.g. before or after food, Service User needs to remain seated after medication?

  • Do Service Users have access to advice/training on their medicines, e.g. inhaler technique?

  • Is advice sought from a pharmacist or GP if staff need clarification on a Service User's medicine?

  • Do Service Users on repeat medicines receive an annual medication review from their GP?

  • Where a Service User has difficulties swallowing and there is no liquid preparation available, is the advice of a GP or pharmacist sought before crushing tablets or opening capsules?

  • If a Service User regularly refuses a medicine, is this raised with their GP?

  • If Monitored Dosage Systems (MDS) are used, is there a process within the home for highlighting medicines that cannot be put in these systems, i.e. medicines susceptible to moisture, e.g. effervescent tablets, liquid medicines, creams, drops etc?

COVID-19 - Are issues being effectively managed?

  • Where the pharmacist has withdrawn the use of Monitored Dosage Systems (Multi- compartment Compliance Aids), are all medicines administered from original packaging?

  • Are all staff trained and competent in the administration of medication from original packaging, rather than the Monitored Dosage System?

  • Is there a record of any changes in medication administration practices being discussed at supervision and team meetings?

  • Are medication risk assessments up to date and do they reflect any change in administration practice?

  • Where drugs are not able to be returned to the pharmacy as regularly as previously, are there appropriate storage, recording and risk assessments completed?

  • Does the service hold any Controlled Drugs that are not prescribed for an individual person?

  • Do all handwritten MAR sheets include the full name of the person, their date of birth and any known allergies?

  • Do all handwritten MAR sheets give the name and details of the medication including strength, form, dose, how often it is given, the route of administration and any special instruction about how the medication should be taken?

  • Are all staff writing the MAR sheets trained and competent to do so and are all handwritten entries signed by a second competent person?

  • Do you use medication to sedate individuals to promote social distancing? If you do, is there evidence to support that this decision is in the person's best interests and has been agreed in a multidisciplinary way?

  • Do medication records and Care Plans reflect the person’s capacity and the changes that may occur during a period of being symptomatic or diagnosed with COVID-19?

  • Do staff consistently administer medication<br>to Service Users in a person-centred manner?

  • When administering medication, do staff always use the correct PPE and follow all required hygiene protocols to prevent the spread of COVID-19?

Medication Audit Completion

  • Date of Audit

  • Audit Completed by (Full Name)

  • Any Action Required? Describe briefly

MAR Audit - CM16

  • Instructions:
    1. Conduct an audit in the last week of the medication cycle to give at least three weeks of administration records.
    2. Collect five MARs and complete the audit.
    3. If the MARs collected do not cover all aspects (e.g. a "when required" medicine), please select another MAR to audit this area.
    4. If there are no Service Users that cover all aspects (e.g. no one taking warfarin), consider re-auditing when possible. 5. Complete the "Action Needed" column including realistic target dates.
    6. Re-audit as necessary.

How Are MARs Completed?

  • Is the writing on the MAR legible?

  • Are all entries on the MAR in ink/printed?

  • If handwritten MARs are used, is there a robust system to check the MAR is correct before it is used?

  • Are handwritten entries on a MAR, cross referenced to the Service User’s notes?

  • Is there a six-monthly audit of use and accuracy of MARs for each Service User?

  • Does the MAR audit cover appropriate and accurate recording, missed/omitted dosages and the use of 'when required' medicines?

  • Are all Service Users' details completed on the front of each MAR?

  • Is the number of MARs in use completed on the front of each MAR?

  • Are all boxes on the MAR signed for regular medicines?

  • Is it clear from the MAR that medication has been given to the Service User?

  • Does the person who gives the medicine sign the MAR?

  • Is there a central list of signatures/initials for staff involved in medication administration?

  • Do the levels of administration support required in the Care Plans tally with the MAR?

  • Are the directions for the administration of a medicine clear on the MAR?

  • Do directions on the MAR match the pharmacy label for that medicine?

  • Are all doses and times clearly stated on the MAR?

  • Is it clear from the directions on the MAR the number of medicines that should be given?

  • If the directions are, for example, ‘1 or 2 tablets...’ is it clear on the MAR if one tablet or 2 tablets have been given?

  • Is it clear when medicines have not been given/have been refused etc?

  • Are medicines given at the correct time?

  • Are the correct codes being used on the MAR?

  • If a prescriber stops a medicine, is this crossed off the chart, dated and signed by an appropriate person?

  • Are charts correctly stored to maintain confidentiality?

Warfarin – How is Warfarin Managed?

  • Is the International Normalised Ratio (INR) result sheet and yellow book stored with the MAR?

  • Are all the details in the general information section of the yellow book?

  • Do all the doses on the MAR match the doses specified in the yellow book, or the INR results sheet, for the audit period?

  • Is the current dose marked clearly in milligrams on the MAR (not the number of tablets)?

  • Warfarin tablets should not be broken in half. Has it been necessary to break any tablets in half in order to administer the prescribed dose?

  • Is the date of the next INR blood test noted on the MAR and/or in a diary?

MAR Audit - Completion

  • Date of Audit

  • Audit Completed by (Full Name)

  • Any Action Required? Describe briefly

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