Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

General Information

  • 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

  • 1.1 Total number of available beds

  • 1.2 Total number of beds occupied?

  • 1.3 Has the previous audit been reviewed and signed off?

  • 1.4 How many corrective actions were raised during the last audit?

  • 1.5 Have all corrective actions raised during the last audit been completed? If not give further details.

Section 2

2 - Management of Medication

  • 2.1 Is there an up to date list of all staff who administer drugs complete with sample signatures?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 2.2 Is there a written procedure for the administration of drugs in use?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 2.3 Have all staff who administer medication been trained and assessed as competent?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 2.4 Is a copy of the BNF available and is this under twelve months old?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 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

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 2.6 Has a cosh assessment been completed for hazardous substances e.g. Cytotoxics, oxygen?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 2.7 Further comments / observations for Management of Medication

Section 3

3 - Ordering of Medication

  • 3.1 Do you have a specific named contact at the surgery and at the pharmacy where medication is ordered?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 3.2 Are there designated members of the team who deal with the ordering of medication?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 3.3 Are all requests for prescriptions auctioned in a timely manner?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 3.4 Is there a procedure in place for obtaining emergency supplies of medicines? E.g out of hours, bank holidays.

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 3.5 Further comments / observations:

Section 4

4 - Medication and Administration

  • 4.1 Is a monitored dosage system in place and if so is it operated satisfactorily in your home?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.2 Are all medicines clearly labelled in accordance with requirements?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.3 Are all medicines within their expiry date?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.4 Does the strength of the medication correspond with that written on the treatment sheet?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.5 Are all medicines appropriately signed for at the time of administration?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.6 Do MAR sheets have a means of identifying the patient? E.g photograph and room number?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.7 Does the MAR sheet tally with the amount of medicine in stock?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.8 If prescription states take 1 or 2 tablets, does the treatment sheet identify clearly wether 1 or 2 are administered?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.9 Do the instructions state 'as directed'? Are instructions clarified with GP before administration?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.10 If medication is PRN does it state in what circumstances it is to be administered?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.11 Is a record made of any doses omitted with a reason why? (I.e. appropriate coding used to acknowledge reason)

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.12 Are all external medications recorded when administered or applied?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.13 Are eye drops and insulin dated when opened and discarded after one month?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.14 Is there evidence of regular medication reviews?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 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?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 4.16 Further comments / observations:

Section 5

5 - Labelling of Medicines

  • 5.1 Do all service users have their own individual supply?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 5.2 Is each medication clearly labelled by a pharmacist or GP?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 5.3 Are labels in original condition and not changed by hand?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 5.4 Is the medication labelled, not just on the outer box (e.g. Labels on tubes and not just the box)?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 5.5 Is a patient information leaflet available for each medicine store at the home?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 5.6 Further comments / observations:

Section 6

6 - Storage of Medication

  • 6.1 Is there a secure and designated storage area for medicines and medicine trolleys?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.2 Are the keys for the medical cupboard and CD cupboard kept separate from other keys?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.3 Is access to these keys and medical storage facilities restricted to authorised staff only?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.4 Are external medications stored in a separate locked cupboard or on a separate shelf in the storage area?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.5 Are all medicinal products, dressings and osteomyelitis products stored off the floor at all times?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.6 When new medication arrives atnthenhome is there a stock rotation system in place?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.7 Are stock levels of reserve drugs acceptable and appropriate for individual use?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.8 Are discontinued / expired medicines removed from the trolley promptly?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.9 Are medicines no longer required returned to pharmacy promptly?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.10 Are all medicines returned to the pharmacy signed for by the accepting pharmacy?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.11 Are all medicines stored in locked cupboards / trolleys? Is the trolley anchored to the wall?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.12 Are there any medications requiring storage in a fridge and if so are they stored correctly?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.13 Is there a maximum / minimum thermometer in the fridge?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.14 Is the fridge regularly cleaned and defrosted?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.15 Is the temperature of the fridge monitored and recorded on a daily basis?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.16 Are staff aware of the procedure to follow if the fridge temperature is outside the 2-8 deg. Range?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.17 Is storage satisfactory for oxygen cylinders and in accordance with the Health & Safety regulations?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.18 Is a warning notice displayed at each location where oxygen is stored or in use?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 6.19 Further comments / observations:

Section 7

7 - Controlled Drugs

  • 7.1 Does the controlled drug cupboard comply with legislative requirements? E.g. Is it a locked cupboard within a locked cupboard?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.2 Is a dedicated controlled drug register available?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.3 Do stock levels held balance with the controlled drug register?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.4 Are all controlled drug administrations witnessed and are two signatures obtained?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.5 Care homes providing personal care: Are CD's administered and witnessed by a designated and appropriately trained member of staff?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.6 Care homes providing nursing care: Are CD's administered by a registered medical,practitioner or registered nurse?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.7 Is a separate page used for each person and each CD?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.8 Further comments / observations:

Section 8

8 - Staff Training

  • 8.1 Have all staff who handle medication received training in the safe handling of medicines?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 8.2 Is all staff training documented?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 8.3 Is training accredited and does it cover the skills for Care Knowledge Set for Medication?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 8.4 Is there a refresher course for staff?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 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?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 8.6 Is there a procedure in place to communicate relevant information within the administration team?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 8.7 Is there a procedure in place for reporting incidents, errors and omissions?

  • Action required

  • By who

  • Date for completion

  • Date completed

  • Sign

  • 7.8 Further comments / observations:

Audit Criteria

Audit Criteria and Additional Comments:

  • Number of records inspected during this audit.

  • Details of records inspected during this audit

  • How many corrective actions were raised from this audit?

  • Audit Completed By:

  • Review Date

  • Audit Reviewed By:

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