joint partnership Wellbeing

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

General

• Where medication issues raised at the last Audit/inspection?

  Yes

  No

  N/A

• If so have they been resolved

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are medications reviewed by a GP every 6 months?

  Yes

  No

  N/A

• Are records available?

  Yes

  No

  N/A

• Are patient information leaflets available for medicines?

  Yes

  No

  N/A

Supply of medicines

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is an appropriate supply system used? Eg bottles/MDS

  Yes

  No

  N/A

• If MDS, is the system used correctly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are medicines clearly labelled?

  Yes

  No

  N/A

• Are multiple packs labelled individually?

  Yes

  No

  N/A

• Is a standard prescription period used in the home

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Storage

• Are the medicines stored in a locked cupboard/trolley?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Where are sip feeds stored, ie Thick and Easy

• Are the keys held by a designated person?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are spare keys secure?

  Yes

  No

  N/A

• Is medication trolley/cupboard cleanliness acceptable?

  Yes

  No

  N/A

Refrigerated items

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

  Yes

  No

  N/A

• Maximum/ minimum fridge thermometer used and reset daily?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is fridge cleanliness acceptable?

  Yes

  No

  N/A

Controlled drugs

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

  Yes

  No

  N/A

• Does this comply with the misuse of safe drugs requirements?

  Yes

  No

  N/A

• Are there spare keys available, where are they kept?

  Yes

  No

  N/A

• Are the keys stored in a safe location?

  Yes

  No

  N/A

• Is there a CD register in use?

  Yes

  No

  N/A

• Does the CD register conform to current specification?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are there two staff signatures for every entry?

  Yes

  No

  N/A

• Are CD stock levels checked at every administration?

  Yes

  No

  N/A

• How often are balances counted, and checked?

  daily

  weekly

  monthly

• Are all records up to date?

  Yes

  No

  N/A

• Are CD's disposed of correctly?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Labelling and Safe Administration

• Is there clear labelling of all medicines?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

• Is the pharmacy informed of medication changes? How?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are there named, dated photographs for all service users?

  Yes

  No

  N/A

• Can staff easily identify people with allergies? How?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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 ?

  Yes

  No

  N/A

• Are medicines supplied for leave/day care clearly recorded?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is the stock levels of medication checked before reordering?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Self Medicators

• Are there any self-Medicators?

  Yes

  No

  N/A

• Are the methods to monitor self-Medicators appropriate?

  Yes

  No

  N/A

• Are there risk assessments available for these self Medicators ?

  Yes

  No

  N/A

• Have the self-Medicators signed a waiver form?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Does the home order medication for these residents?

  Yes

  No

  N/A

• Does the home have a self-Medicators policy?

  Yes

  No

  N/A

Medication Training

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Number of staff administering medicines?

• Number of staff that have received the appropriate training?

• Date of the last Medication Administration training day?

  Date

• Who carried out the Training Session?

Safe system for disposal of medicines

• Return books available

  Yes

  No

  N/A

• All medicines to be returned are recorded?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Entry made in CD register and stock level updated?

  Yes

  No

  N/A

General

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A