Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
General Information
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During this audit, one student record should be used as a sample during the audit process. If any errors are found, a further two records should be audited. If any further errors are found this will necessitate a full audit of all student
Student records used for sampling during audits should be selected on a rotational basis.
Section 1
1 - Overview
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1.1 Total number of available beds
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1.2 Total number of beds occupied?
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1.3 Has the previous audit been reviewed and signed off?
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1.4 How many corrective actions were raised during the last audit?
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1.5 Have all corrective actions raised during the last audit been completed? If not give further details.
Section 2
2 - Management of Medication
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2.1 Is there an up to date list of all staff who administer drugs complete with sample signatures?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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2.2 Is there a written procedure for the administration of drugs in use?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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2.3 Have all staff who administer medication been trained and assessed as competent?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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2.4 Is a copy of the BNF available and is this under twelve months old?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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2.5 Is there a policy in place for:<br>Obtaining, Receipt and Storage of medicines<br>Handling and Administration of medicines<br>Monitoring of medicines<br>Disposal of medicines<br>Handling and Review of incidents / errors / near misses<br>Homely Remedies<br>Covert medication<br>Social Leave<br>Self-administration of medication
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Action required
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By who
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Date for completion
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Date completed
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Sign
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2.6 Has a cosh assessment been completed for hazardous substances e.g. Cytotoxics, oxygen?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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2.7 Further comments / observations for Management of Medication
Section 3
3 - Ordering of Medication
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3.1 Do you have a specific named contact at the surgery and at the pharmacy where medication is ordered?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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3.2 Are there designated members of the team who deal with the ordering of medication?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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3.3 Are all requests for prescriptions auctioned in a timely manner?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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3.4 Is there a procedure in place for obtaining emergency supplies of medicines? E.g out of hours, bank holidays.
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Action required
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By who
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Date for completion
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Date completed
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Sign
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3.5 Further comments / observations:
Section 4
4 - Medication and Administration
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4.1 Is a monitored dosage system in place and if so is it operated satisfactorily in your home?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.2 Are all medicines clearly labelled in accordance with requirements?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.3 Are all medicines within their expiry date?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.4 Does the strength of the medication correspond with that written on the treatment sheet?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.5 Are all medicines appropriately signed for at the time of administration?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.6 Do MAR sheets have a means of identifying the patient? E.g photograph and room number?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.7 Does the MAR sheet tally with the amount of medicine in stock?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.8 If prescription states take 1 or 2 tablets, does the treatment sheet identify clearly wether 1 or 2 are administered?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.9 Do the instructions state 'as directed'? Are instructions clarified with GP before administration?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.10 If medication is PRN does it state in what circumstances it is to be administered?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.11 Is a record made of any doses omitted with a reason why? (I.e. appropriate coding used to acknowledge reason)
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.12 Are all external medications recorded when administered or applied?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.13 Are eye drops and insulin dated when opened and discarded after one month?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.14 Is there evidence of regular medication reviews?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.15 Where additional knowledge is required for administration e.g. Insulin, PEG tubes, rectal products have staff been trained in these techniques including formal assessment of competency?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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4.16 Further comments / observations:
Section 5
5 - Labelling of Medicines
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5.1 Do all service users have their own individual supply?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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5.2 Is each medication clearly labelled by a pharmacist or GP?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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5.3 Are labels in original condition and not changed by hand?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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5.4 Is the medication labelled, not just on the outer box (e.g. Labels on tubes and not just the box)?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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5.5 Is a patient information leaflet available for each medicine store at the home?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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5.6 Further comments / observations:
Section 6
6 - Storage of Medication
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6.1 Is there a secure and designated storage area for medicines and medicine trolleys?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.2 Are the keys for the medical cupboard and CD cupboard kept separate from other keys?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.3 Is access to these keys and medical storage facilities restricted to authorised staff only?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.4 Are external medications stored in a separate locked cupboard or on a separate shelf in the storage area?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.5 Are all medicinal products, dressings and osteomyelitis products stored off the floor at all times?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.6 When new medication arrives atnthenhome is there a stock rotation system in place?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.7 Are stock levels of reserve drugs acceptable and appropriate for individual use?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.8 Are discontinued / expired medicines removed from the trolley promptly?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.9 Are medicines no longer required returned to pharmacy promptly?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.10 Are all medicines returned to the pharmacy signed for by the accepting pharmacy?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.11 Are all medicines stored in locked cupboards / trolleys? Is the trolley anchored to the wall?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.12 Are there any medications requiring storage in a fridge and if so are they stored correctly?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.13 Is there a maximum / minimum thermometer in the fridge?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.14 Is the fridge regularly cleaned and defrosted?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.15 Is the temperature of the fridge monitored and recorded on a daily basis?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.16 Are staff aware of the procedure to follow if the fridge temperature is outside the 2-8 deg. Range?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.17 Is storage satisfactory for oxygen cylinders and in accordance with the Health & Safety regulations?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.18 Is a warning notice displayed at each location where oxygen is stored or in use?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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6.19 Further comments / observations:
Section 7
7 - Controlled Drugs
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7.1 Does the controlled drug cupboard comply with legislative requirements? E.g. Is it a locked cupboard within a locked cupboard?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.2 Is a dedicated controlled drug register available?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.3 Do stock levels held balance with the controlled drug register?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.4 Are all controlled drug administrations witnessed and are two signatures obtained?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.5 Care homes providing personal care: Are CD's administered and witnessed by a designated and appropriately trained member of staff?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.6 Care homes providing nursing care: Are CD's administered by a registered medical,practitioner or registered nurse?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.7 Is a separate page used for each person and each CD?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.8 Further comments / observations:
Section 8
8 - Staff Training
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8.1 Have all staff who handle medication received training in the safe handling of medicines?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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8.2 Is all staff training documented?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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8.3 Is training accredited and does it cover the skills for Care Knowledge Set for Medication?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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8.4 Is there a refresher course for staff?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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8.5 Is there a procedure in place to deal with all relevant medicine related patient safety communications issued via alert systems within the required timescales?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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8.6 Is there a procedure in place to communicate relevant information within the administration team?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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8.7 Is there a procedure in place for reporting incidents, errors and omissions?
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Action required
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By who
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Date for completion
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Date completed
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Sign
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7.8 Further comments / observations:
Audit Criteria
Audit Criteria and Additional Comments:
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Number of records inspected during this audit.
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Details of records inspected during this audit
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How many corrective actions were raised from this audit?
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Audit Completed By:
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Review Date
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Audit Reviewed By: