Audit

General

Where medication issues raised at the last Audit/inspection?

If so have they been resolved

Is there a policy and system in place for safe and appropriate medication administration?

Are medications reviewed by a GP every 6 months?

Are records available?

Are patient information leaflets available for medicines?

Supply of medicines

Are all prescribed medicines, dressings and appliances for use by individual patients?

Is there a written procedure for ordering, receipt, storage, administration and disposal of medicines that meets the latest standards?

Is an appropriate supply system used? Eg bottles/MDS

If MDS, is the system used correctly?

Is a supply available for individual residents? (no borrowing/sharing)

Are medicines clearly labelled?

Are multiple packs labelled individually?

Is a standard prescription period used in the home

Do any service users or family buy medicines for the service user to take?

Has all the medicine which has been received been appropriately logged and recorded?

Storage

Are the medicines stored in a locked cupboard/trolley?

Is the trolley secured to "the fabric of the building" when not in use?

Where are sip feeds stored, ie Thick and Easy

Are the keys held by a designated person?

Is the key holder listed on a registrar of suitably trained staff.

Is there a suitable handover process for the keys at the start and end of each shift? If yes what happens to the keys?

Are spare keys secure?

Is medication trolley/cupboard cleanliness acceptable?

Refrigerated items

Are appropriate medicines stored in a lockable fridge? If no where and how are they stored?

Maximum/ minimum fridge thermometer used and reset daily?

Temperatures recorded daily and in the range 2-8 centigrade?

Are only fridge medication lines stored in the fridge? If no what else is stored?

Is fridge cleanliness acceptable?

Controlled drugs

Are all CD's stored in a separate, locked metal cabinet?

Does this comply with the misuse of safe drugs requirements?

Are there spare keys available, where are they kept?

Are the keys stored in a safe location?

Is there a CD register in use?

Does the CD register conform to current specification?

Is there a written procedure that details the system of ordering, receipt, administration and disposal of CD's within the care home?

Does the current stock match that recorded in the CD register?

Are there two staff signatures for every entry?

Are CD stock levels checked at every administration?

How often are balances counted, and checked?

Are all records up to date?

Are CD's disposed of correctly?

Administration of CD's recorded on MARR and CD register?

Labelling and Safe Administration

Is there clear labelling of all medicines?

Are all administration instructions on medication clear enough to ensure accurate administration? If any read "as directed" or similar, what action has been taken to gain directions?

Is there a MARR's chart available for all residents taking medicines?

Is the MARR's chart completed correctly and legible at the time of this audit?

Resident 1, All the MARR's Chart has been completed up to date and time correctly and legibly. ( please list resident identifier in notes).

Resident 2, All the MARR's Chart has been completed up to date and time correctly and legibly. ( please list resident identifier in notes).

Resident 3, All the MARR's Chart has been completed up to date and time correctly and legibly. ( please list resident identifier in notes).

If the medicine has a variable dose is the actual quantity given and recorded?

Is the prescriber informed after an agreed number of doses have been refused and this is recorded?

Medicine 1, Do the stock levels match those calculated on the MARR's chart? (pick one random medicine and list in notes).

Medicine 2, Do the stock levels match those calculated on the MARR's chart? (pick one random medicine and list in notes).

Medicine 3, Do the stock levels match those calculated on the MARR's chart? (pick one random medicine and list in notes).

Is there a system in place to keep the MARR sheet up to date after changes have been made to the medication by the prescriber?

Is the pharmacy informed of medication changes? How?

Is the medication always administered directly from a container labelled by the pharmacy?

Is there a process to administer medicines if the service user is out of the home at the time medicine should be given e.g day centre?

If an MDS system is used, is this being used appropriately?

Are there named, dated photographs for all service users?

Can staff easily identify people with allergies? How?

Does the home have a written procedure to deal with and record medication errors?

Question staff member about procedure of medication error reporting, did they describe the procedure well? (list staff member questioned in notes)

Are residents able to consent to treatment ?

Are medicines supplied for leave/day care clearly recorded?

Are all dressings, catheters and bags used recorded? How?

Are all expiry dates checked regularly and is there a record kept?

Are short life medicines dated on ending?
(Eg insulin vials usually have a 4 week life, eye drops and ointments 28 days after opening)

Is medication ordered from anywhere other than the usual pharmacy recorded on the MARR chart with two staff signatures.

Is the stock levels of medication checked before reordering?

Is there an up to date list available of staff able to administer medicines with examples of their signatures and initials?

Do we have a copy of local guidelines eg wound, continence and sip feeds?

Self Medicators

Are there any self-Medicators?

Are the methods to monitor self-Medicators appropriate?

Are there risk assessments available for these self Medicators ?

Have the self-Medicators signed a waiver form?

Does the resident have lockable facilities for safe storage of these medicines? And do staff have access with permission?

Does the home order medication for these residents?

Does the home have a self-Medicators policy?

Medication Training

Have all staff responsible for administering medication received the appropriate training? And can this been demonstrated?

Have these staff been assessed as competent in the work place?

Number of staff administering medicines?

Number of staff that have received the appropriate training?

Date of the last Medication Administration training day?

Who carried out the Training Session?

Safe system for disposal of medicines

Return books available

All medicines to be returned are recorded?

Where he return book is used to document returns is there a staff signature on all occasions?

CD's returned on a separate sheet, and handed directly to the driver?

Entry made in CD register and stock level updated?

General

Does the home have an appropriate reference source for medication? Eg BNF.

Are there systems in place to facilitate information sharing regarding medication when the resident moves from one care environment to another?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.