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Ordering – How Medicines Are Ordered?

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

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

  • Are there any ordering/stock problems?

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

  • Are there any problems with the pharmacy or GP surgery?

  • Are records kept of medicines ordered?

  • Are records kept of medicines received?

  • Are discrepancies in the above raised with the community pharmacists and/or GP?

  • Are all medicines checked in correctly?

  • Are medicines clearly labelled by the Pharmacist?

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

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

Storage - How Are Medicines Stored?

  • Are medicines stored safely and securely in an appropriate designated area?

  • Are storage areas clean and organised?

  • Is the medicines cupboard kept locked when not in use?

  • Are keys kept as per policy?

  • Are excessive quantities of medication being stored?

  • Are expiry dates checked monthly – both prescribed and over the counter medicines?

  • Is there a record of expiry date checks?

  • Are external medications separated from internal medications where appropriate?

  • Are there arrangements in place for Residentss who self-medicate to safely store their own medication?

  • Is stock rotated appropriately?

  • Is there any evidence of borrowing/sharing of medication?

  • Are oxygen cylinders stored upright, in a well- ventilated area away from heat and flames?

  • Are 'No Smoking' signs displayed?

Fridge Storage – How Are Fridge Items Stored?

  • Are medicines requiring refrigeration stored appropriately in a secure area?

  • Are there any items stored in the fridge that shouldn’t be stored in it?

  • Are items requiring refrigeration put away as soon as they are received?

  • Is there a process for stock rotation where the Residents has more than one bottle/box of the same medicine?

  • Are there signs that state the fridge should not be switched off?

  • Do staff know not to overstock the fridge to make sure there is space for the air to circulate?

  • Do staff know to keep the fridge door open for as short a time as possible to keep a constant temperature?

  • Do staff check that products are not frozen before administering to a Residents?

  • Does the fridge have a maximum/ minimum thermometer?

  • Are all maximum/minimum fridge temperatures checked daily and the records kept?

  • Is action taken if the fridge temperatures are outside the normal range of 2-8 °C?

  • Is this action documented and retained?

  • Is the fridge cleaned and defrosted at least quarterly?

  • Do staff know what to do if the fridge breaks down?

Controlled Drugs - How Are Controlled Drugs Managed?

  • Are stock levels of controlled drugs appropriate?

  • Does the quantity in the CD register reflect the actual stock?

  • Is the administration of controlled drugs in line with current policy?

  • Are controlled drugs disposed of appropriately?

Disposal - How is Medication Disposed of?

  • Has medication been held for a sufficient time following a death?

  • Are any medicines destroyed in the home?

  • Is the returns record up to date?

  • Is medication for disposal separated from medicines in use?

Homely Remedies- How Are Homely Remedies Managed?

  • Does the audit trail of homely remedies tally?

  • Are all homely remedies in date?

  • Are homely remedies stored separately and securely?

  • Have any homely remedies been given for more than 2 days without contacting the GP?

Self-Managed Medication - How Are Self-Managing Residentss Supported?

  • Is there evidence that Residentss are encouraged and supported to selfmanage their medication?

  • Do current Residentss who self-manage have safe, lockable storage facilities for their medication?

  • Are risk assessments completed for current Residentss who self-manage?

  • Are verbal reminders/supervision/ monitoring given (and documented) for Residentss who require them?

  • Is discreet monitoring and reassessment being carried out?

Obtaining Consent for Medication Administration?

  • Is there a process for obtaining Residentss' consent if staff administer medication?

Records - How Are Records Managed?

  • Are all administrations of medicines recorded in the appropriate place, i.e. medicines chart, Residents's notes, CD register?

  • Is the administration of medicines recorded as soon as possible after the Residents has taken the medicine?

  • Are all omissions of medicines recorded in the appropriate place, i.e. MARs, Residents's notes.

  • Is there a process for verbal orders from a GP?

Medication Administration – How Are Medicines Administered?

  • Are medicines administered from original containers as received from the pharmacy, one Residents at a time?

  • Are labels printed clearly?

  • Are dosage instructions clear?

  • Have any labels been defaced or changed?

  • Are appropriate cautions and warnings clear?

  • Are all medicines labelled for individual Residentss (including medications for external use)?

  • If a monitored dosage system (MDS) is in use, are appropriate cautions and warnings clear and is there an appropriate dispensing date on the pack currently being used?

  • Is there a risk assessment for each Residents who self-medicates any of their medicines?

  • Are measures in place to identify Residentss to ensure that they receive the correct medicine?

  • Have all staff who are involved with prescribing and/or administering medicines read the suite of medication management policies at Aims Care Limited T/A Leighton House Nursing Home?

  • Is there a signatory list to demonstrate that staff have read and understood the policies?

  • Are allergies checked before a medicine is administered to a Residents?

  • Are medicines administered to Residentss from their original containers?

  • Is a drink offered when administering a Residents’s medicine?

  • Are medicines with short expiry dates, e.g. drops, some liquids, etc. dated when they are opened?

  • Are special instructions observed when administering medicines, e.g. before or after food, Residents needs to remain seated after medication?

  • Do Residentss have access to advice/training on their medicines, e.g. inhaler technique?

  • Is advice sought from a pharmacist or GP if staff need clarification on a Residents's medicine?

  • Do Residentss on repeat medicines receive an annual medication review from their GP?

  • Where a Residents has difficulties swallowing and there is no liquid preparation available, is the advice of a GP or pharmacist sought before crushing tablets or opening capsules?

  • If a Residents regularly refuses a medicine, is this raised with their GP?

  • If Monitored Dosage Systems (MDS) are used, is there a process within the home for highlighting medicines that cannot be put in these systems, i.e. medicines susceptible to moisture, e.g. effervescent<br>tablets, liquid medicines, creams, drops, etc.?

How Are MARs Completed?

  • Is the writing on the MAR legible?

  • Are all entries on the MAR in ink/printed?

  • Are handwritten entries on a MAR, cross referenced to the Residents’s notes?

  • Are all Residentss' details completed on the front of each MAR?

  • Is the number of MARs in use completed on the front of each MAR?

  • Are all boxes on the MAR signed for regular medicines?

  • Is it clear from the MAR that medication has been given to the Residents?

  • Does the person who gives the medicine sign the MAR?

  • Is there a central list of signatures/initials for staff involved in medication administration?

  • Do the levels of administration support required in the Care Plans tally with the MAR?

  • Are the directions for the administration of a medicine clear on the MAR?

  • Do directions on the MAR match the pharmacy label for that medicine?

  • Are all doses and times clearly stated on the MAR?

  • Is it clear from the directions on the MAR the number of medicines that should be given?

  • If the directions are, for example, ‘1 or 2 tablets…’ is it clear on the MAR if 1 tablet or 2 tablets have been given?

  • Is it clear when medicines have not been given/have been refused, etc.?

  • Are medicines given at the correct time?

  • Are the correct codes being used on the MAR?

  • If a prescriber stops a medicine, is this crossed off the chart, dated and signed by an appropriate person?

  • Are charts correctly stored to maintain confidentiality?

Warfarin – How is Warfarin Managed?

  • Is the International Normalised Ratio (INR) result sheet and yellow book stored with the MAR?

  • Are all the details in the general information section of the yellow book?

  • Do all the doses on the MAR match the doses specified in the yellow book, or the INR results sheet, for the audit period?

  • Is the current dose marked clearly in milligrams on the MAR (not the number of tablets)?

  • Warfarin tablets should not be broken in half. Has it been necessary to break any tablets in half in order to administer the prescribed dose?

  • Is the date of the next INR blood test noted on the MAR and/or in a diary?

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