Medication Audit

• Site/ Location

  Select

• Conducted on

  Date

• Auditor

GENERAL

• Are all medication storage areas, trolleys, and cupboards<br>clean and tidy?

  Yes

  No

  N/A

• Were the medication cupboard/cabinets locked?

  Yes

  No

  N/A

• Are daily stock checks of medication carried out?

  Yes

  No

  N/A

• Is there written evidence of medication audits and spot checks?

  Yes

  No

  N/A

• Has action been taken to rectify any issues found during audits?

  Yes

  No

  N/A

• Are daily temperature checks made and recorded for all clinical fridges, using a max/min thermometer?

  Yes

  No

  N/A

• Are the clinical fridge temperature checks within the correct range of 2-8C? If not, has action been taken to rectify this?

  Yes

  No

  N/A

• Is the medication room temperature checked (no higher than 25C)

  Yes

  No

  N/A

• has action been taken to rectify this?

  Yes

  No

  N/A

• Are there written records of weekly checks and cleaning of all emergency equipment such as LM breathing mask??

  Yes

  No

  N/A

• Are the medication keys held by the person in charge at all times?

  Yes

  No

  N/A

• Are the medication charts completed correctly (no gaps and correct codes)

  Yes

  No

  N/A

• Is the medicine trolley secured to the wall when not in use?

  Yes

  No

  N/A

• Are internal medicines stored separately from external<br>medicines?

  Yes

  No

  N/A

• Is the medication room and storage areas for prescribed items, such as dressings, kept locked when not in use?

  Yes

  No

  N/A

• Do all clinical fridges have working locks and keys? Are they kept locked when not in use?

  Yes

  No

  N/A

• Is there an up to date signature list of medication trained staff

  Yes

  No

  N/A

• Are the boxes containing medication clean and in a good state of repair ?

  Yes

  No

  N/A

Topical Medications

• A Topical Medicines Application Record (TMAR) and body map is completed for each topical medication prescribed.

  Yes

  No

  N/A

• Each TMAR has a body map alongside to indicate where the cream/ointment is to be applied by placing an X on the body area.

  Yes

  No

  N/A

• The TMAR clearly states what is to be applied, the frequency and how to apply, e.g. apply emollient liberally to dry skin on legs, or apply steroid cream thinly to face as shown on body map.

  Yes

  No

  N/A

• Does the Topical medication have a date of opening on it?

  Yes

  No

  N/A

• All topical medication are in date?

  Yes

  No

  N/A

• The TMAR is stored in the area where the topical medicine will be applied, e.g. the Residents’ room.

  Yes

  No

  N/A

• Care staff sign the EMAR at the time they apply a topical medicine in line with the prescription<br>instructions

  Yes

  No

  N/A

• Each resident has a Care Plan written for each topical medicine applied.

  Yes

  No

  N/A

• A risk assessment is in place to consider the safe handling and storage of the creams/ointment (including the risk of fire)

  Yes

  No

  N/A

• Care staff ensure the relevant topical medicines Patient Information Leaflet (PIL) is kept and is available.

  Yes

  No

  N/A

Covert and self administering

• There is evidence that Residents are encouraged and supported to self-manage their medication?

  Yes

  No

  N/A

• Do current Residents who self administer have safe, lockable storage facilities for their medication?

  Yes

  No

  N/A

• Do all Residents that self-administer have an assessment in place?

  Yes

  No

  N/A

• Do all Residents who self-administer have a detailed Care Plan in place?

  Yes

  No

  N/A

• Is discreet monitoring and reassessment being carried out?

  Yes

  No

  N/A

• Have all Residents who are having their medication administered covertly been assessed under the Mental Capacity Act 2005? A capacity assessment is in evidence?

  Yes

  No

  N/A

• Do all Residents who are having their medication administered covertly have a detailed Care Plan in place?

  Yes

  No

  N/A

• Are regular reviews taking place of the decision to give medication covertly?

  Yes

  No

  N/A

Ordering and returns

• Are all medications brought into the service and disposed of within the Home recorded?

  Yes

  No

  N/A

• Are medicines that are no longer in use returned and not retained for other Residents, or beyond the "use by date"?

  Yes

  No

  N/A

• Are the staff responsible for medication aware of the procedures for ordering medication out with normal hours?

  Yes

  No

  N/A

• Are all unused medications returned to pharmacy and is the reason for any returns stated in the returns book?

  Yes

  No

  N/A

• Are stock rotation procedures followed, especially for PRN medications, homely remedies, and any non-blistered items

  Yes

  No

  N/A

• Does the Home have an adequate supply of medication for each Resident, with no evidence of overstocking medicines?

  Yes

  No

  N/A

• Do all records show that medicines are NEVER out of stock?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is there an agreed method for requesting repeat prescription orders from GP practice(s)?

  Yes

  No

  N/A

• Are there any ordering/stock problems?

  Yes

  No

  N/A

• Are medicines ordered in advance, so Residents do not miss any dosages of their medicines?

  Yes

  No

  N/A

• Are records kept of medicines ordered?

  Yes

  No

  N/A

• Are records kept of medicines received?

  Yes

  No

  N/A

• Are discrepancies in the above raised with the MOCH Team and/or GP?

  Yes

  No

  N/A

• Are all medicines checked in correctly?

  Yes

  No

  N/A

• Are medicines clearly labelled by the Pharmacy?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is there a register of all homely remedies purchased, with a record of administration?

  Yes

  No

  N/A

• Have receipts of purchase been kept with the homely remedy record?

  Yes

  No

  N/A

• All homely remedies purchased are in line with the self care toolkit?

  Yes

  No

  N/A

• Where a homely remedy is bought by a Resident (that is not covered by policy) is there is separate written consent obtained from the GP?

  Yes

  No

  N/A

• Are all homely remedies stored within the medication room?

  Yes

  No

  N/A

• Does the running total in the homely remedies register match with the stock balance?

  Yes

  No

  N/A

• Are all homely remedies within their expiry date?

  Yes

  No

  N/A

• Is there a separate individual record of administration of homely remedies for each Resident kept with their medication administration records?

  Yes

  No

  N/A

• Have more than two consecutive doses of any homely remedy been administered without medical advice being sought?

  Yes

  No

  N/A

• Are all received medications clearly recorded in CD register?

  Yes

  No

  N/A

• Are all returned medications clearly recorded in CDregister and returns book?

  Yes

  No

  N/A

• Are Weekly checks of CDs are being carried out and recorded by an appropriate person?

  Yes

  No

  N/A

• Are CD’s stored securely within a separate locked CD cupboard?

  Yes

  No

  N/A

• CD keys always carried by the person in charge and kept separate from other medication keys?

  Yes

  No

  N/A

• Do quantities in the CD register match actual stock in the cupboard?

  Yes

  No

  N/A

• Are all current-controlled drug registers locked in the CD cupboard when not in use?

  Yes

  No

  N/A

MARR CHART COVER

• Are all the details on the medication EMARR completed?

  Yes

  No

  N/A

• Is there a current and clear photo of the client on their MARR chart?

  Yes

  No

  N/A

• Has the Residents photo been updated in the last 12 months

  Yes

  No

  N/A

• Does the chart cover clearly state any known allergies

  Yes

  No

  N/A

REGULAR MEDICATIONS

• Is the clients name and D.O.B. clearly identifiable on each medication?

  Yes

  No

  N/A

• All medications have an opening date clearly legible

  Yes

  No

  N/A

• Have all ceased regular medications been signed off and dated (with Dr's name)

  Yes

  No

  N/A

• Does the label on the medication match the Doctors orders in the MARR?

  Yes

  No

  N/A

• Are all non packed medications easily identifiable on the medication charts?

  Yes

  No

  N/A

• Are all non packed medications in date?

  Yes

  No

  N/A

• Have all regular medications been signed for?

  Yes

  No

  N/A

• Where a Resident has refused medication, it is clearly recorded on the MARR?

  Yes

  No

  N/A

• Where a resident has refused there medication 3 or more times GP advice has been sought and followed?

  Yes

  No

  N/A

PRN MEDICATIONS

• Are there individual containers that are clearly identifiable to store PRN medications?

  Yes

  No

  N/A

• Are all PRN medications in date?

  Yes

  No

  N/A

• Are all PRN medication placed in individual containers?

  Yes

  No

  N/A

• Each PRN medication has a Protocol in place- describing the desired outcome, when to administer and dose.

  Yes

  No

  N/A

• The reason for the administration of any PRN has been recorded on the PRN Protocol

  Yes

  No

  N/A

• The effect of any administered PRN medication has been recorded

  Yes

  No

  N/A

• The amount given has been recorded for any variable doses

  Yes

  No

  N/A

• Persistently required PRN Medications or those not achieving the desired outcome are reviewed by the GP

  Yes

  No

  N/A

• PRN protocols are reviewed monthly and changes made as they occur

  Yes

  No

  N/A

CONFORMITIES

• How many NON-CONFORMITIES are in this audit

  Select None one two three four five six seven eight nine ten eleven twelve twelve plus

  • None
  • one
  • two
  • three
  • four
  • five
  • six
  • seven
  • eight
  • nine
  • ten
  • eleven
  • twelve
  • twelve plus

• Additional Information

ACTION TO REMEDY NON-CONFORMITIES

• Are there any Actions to Remedy Non-CONFORMITIES?

  No

  Yes

• Due By

  Date

• Persons Responsible

SIGNATURE OF AUDITOR

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