Medications Audit

• Month Covered

• Conducted on

  Date

• Home

  Select The Manor House Magnolia House Moorgate Croft Moorgate Hollow Moorgate Lodge Croston Park The Hall

  • The Manor House
  • Magnolia House
  • Moorgate Croft
  • Moorgate Hollow
  • Moorgate Lodge
  • Croston Park
  • The Hall

• Prepared by

Documentation

• Are copies of the medicines policy stored on each unit?

  Yes

  No

  N/A

• Are there copies of NMC standards for medications? (Nursing Homes)

  Yes

  No

  N/A

• Does the home have a copy of the Royal Pharmaceutical Standards in each treatment room and office?

  Yes

  No

  N/A

• Is there a BNF in each treatment room which is no older than 1 year old?

  Yes

  No

  N/A

• Are all medicines correctly labelled?

  Yes

  No

  N/A

• Are all medicines within their expiry date?

  Yes

  No

  N/A

• Are dates of opening written on all boxes / bottles?

  Yes

  No

  N/A

• Is there a photograph of each resident with their MAR chart? Is it no older than 6 months?

  Yes

  No

  N/A

• If medicines are withheld, is the reason documented in the care plan?

  Yes

  No

  N/A

• Are medicine records maintained and organised to show a clear audit trail?

  Yes

  No

  N/A

• Are medicines arriving in the ome documented correctly?

  Yes

  No

  N/A

• Are medicines that are disposed of or returned documented correctly?

  Yes

  No

  N/A

• Are known allergies documented on the resident ID and MAR sheet?

  Yes

  No

  N/A

• Are duplicate name alerts in place if applicable?

  Yes

  No

  N/A

• Is the MAR sheet fully completed with no gaps in signing or codes?

  Yes

  No

  N/A

• Are all entries on MAR sheets in black ink, with no evidence of tippex use?

  Yes

  No

  N/A

• Are variable doses clearly recorded?

  Yes

  No

  N/A

• Are all directions clear, with no evidence of 'as directed' or 'give as required' on MAR sheets?

  Yes

  No

  N/A

• Are directions on MAR sheets exactly the same as direction on blister pack / bottle / box?

  Yes

  No

  N/A

• Do handwritten entries on MAR sheets have two staff signatures and are dated?

  Yes

  No

  N/A

• Do any handwritten changes on MAR sheets have two signatures and are dated?

  Yes

  No

  N/A

• Do all items received into the home have 2 staff signatures and are dated?

  Yes

  No

  N/A

• Is all stock carried forward from last month clearly documented on MAR sheets?

  Yes

  No

  N/A

• Do all PRN medications have appropriate code or signature with no gaps on MAR sheets?

  Yes

  No

  N/A

• Do all PRN medications have a corresponding care plan?

  Yes

  No

  N/A

• Are all creams / supplements / dressings signed for on MAR sheets?

  Yes

  No

  N/A

• Do all medicine labels have clear directions and have not been altered?

  Yes

  No

  N/A

• Is the Controlled Drugs Book completed correctly?

  Yes

  No

  N/A

• Do the recorded quantity of controlled drugs match the amount in the CD cupboard?

  Yes

  No

  N/A

• Are all CDs signed for on entry and exit from the home by 2 members of staff?

  Yes

  No

  N/A

• Do all administered CDs have 2 signatures in the CD book?

  Yes

  No

  N/A

• Are there at least weekly CD checks undertaken and documented by staff?

  Yes

  No

  N/A

Procedure

• Are all medicines - including dressings and feeds - only used for the person for whom it was prescribed?

  Yes

  No

  N/A

• If discrepancies are noticed the correct procedure is followed?

  Yes

  No

  N/A

• Do all staff who administer medications know what to do in the event of a missing medication (ask person dispensing that shift)?

  Yes

  No

  N/A

• Do all staff who administer medications know what to do in the event of a drug error (ask person dispensing that shift)?

  Yes

  No

  N/A

• Is there NO evidence of dressings being kept from residents who are no longer at the home?

  Yes

  No

  N/A

• Are all staff administering medications aware of the procedure for obtaining medicines outside of the normal hours of supply?

  Yes

  No

  N/A

• Are all unused medications returned to the pharmacy and recorded?

  Yes

  No

  N/A

• Are stock rotation procedures followed?

  Yes

  No

  N/A

• Does the home have an adequate stock of medication, with not evidence of over or under stocking?

  Yes

  No

  N/A

• Do all records show that medicine is never out of stock?

  Yes

  No

  N/A

• Are any changes to dosage following any tests clearly recorded?

  Yes

  No

  N/A

• If covert administration is being used, is it clearly recorded and is there evidence of multi-disciplinary best interest decisions in care plan?

  Yes

  No

  N/A

• Are medicines of deceased residents kept within the home for 7 days following death, unless specified different by coroner?

  Yes

  No

  N/A

• Is there a clear audit trail for stock balances at any time within the month? Check 5 to ensure correct amount of medicine remains

  Yes

  No

  N/A

• Are medicines given to the resident by the person dispensing the drug - is there no evidence of other staff being asked to give medicines to residents?

  Yes

  No

  N/A

• Do staff always maintain resident safety by not leaving medicines with residents 'to take later'?

  Yes

  No

  N/A

• Are medicine trolleys always locked when staff are not present?

  Yes

  No

  N/A

• Are medicine keys always in possession of the person who is able to administer medications and are never left in trolley door etc. ?

  Yes

  No

  N/A

• Do staff administering medications receive as few disruptions as possible, and are not broken off for non emergency tasks?

  Yes

  No

  N/A

Storage

• Are all medicines stored in locked cupboards?

  Yes

  No

  N/A

• Are there adequate lockable cupboards and hand washing facilities in the area that medicines are stored?

  Yes

  No

  N/A

• Are medicine trolleys clean and free from debris?

  Yes

  No

  N/A

• Are all medicine cupboards used exclusively for the storage of medicines and no other items are found?

  Yes

  No

  N/A

• Is there a separate lockable cupboard for all CDs which is in line with regulations? The cupboard should be double lockable or a locked cupboard within a locked cupboard

  Yes

  No

  N/A

• Is the Controlled Drug cupboard used exclusively for the storage of Controlled Drugs? Are there no other items being stored within it?

  Yes

  No

  N/A

• Are all medicine trolleys locked and secured to the wall when not in use?

  Yes

  No

  N/A

• Are all drug storage areas clean?

  Yes

  No

  N/A

• Is the clinical room floor clean and in good condition?

  Yes

  No

  N/A

• Are any medicines fridges clean and free from frost?

  Yes

  No

  N/A

• Are medicine fridge temperatures recorded daily?

  Yes

  No

  N/A

• Are all medicine fridges operating at the correct temperature of between 2 - 8 degrees C?

  Yes

  No

  N/A

• Are daily clinical room temperatures recorded?

  Yes

  No

  N/A

• Is the temperature of the clinical room no higher than 25C?

  Yes

  No

  N/A

• If the clinical room is used for other purpose - what is done to ensure any medicines contained within it are temperature controlled?

  Yes

  No

  N/A

• Is there a record of all signatures and initials of staff who administer medicines?

  Yes

  No

  N/A

• Is any emergency equipment checked weekly and is this recorded?

  Yes

  No

  N/A

• Are blood sugar monitors calibrated weekly?

  Yes

  No

  N/A

• Are spare medicine keys stored in a secure locked area?

  Yes

  No

  N/A

• Are medicine keys carried by a RN or Senior Care Assistant (residential care) only?

  Yes

  No

  N/A

Self Administration

• When a resident is self administering any medication, is there evidence within the care file that a full risk assessment has been completed?

  Yes

  No

  N/A

• Do all residents self administering have a lockable and secure area in which to store their medications?

  Yes

  No

  N/A

• For residents self administering, is the MAR sheet signed when medication is issued to the resident, and the quantity recorded?

  Yes

  No

  N/A

• Do MAR sheets records show each drug that is self administered by the resident as 'self administering'?

  Yes

  No

  N/A

• Do all residents who self administer have a corresponding care plan?

  Yes

  No

  N/A

Homely Remedies

• Does the home have a list of approved homely remedies, and this had been approved and signed by the residents GP? Is it reviewed annually?

  Yes

  No

  N/A

• Is there evidence that expiry dates of homely remedies are checked regularly?

  Yes

  No

  N/A

• Are all homely remedies within date?

  Yes

  No

  N/A

• Are all homely remedies administered recorded on the correct area of the MAR sheet?

  Yes

  No

  N/A

• Are all homely remedies administered recorded within the residents care file?

  Yes

  No

  N/A

Oxygen

• Are hazard signs available and used during administration and in storage areas?

  Yes

  No

  N/A

• Are trolleys available for safe handling and movement of oxygen canisters?

  Yes

  No

  N/A

• Is all oxygen equipment operational and clean?

  Yes

  No

  N/A

• Are face masks clean and covered?

  Yes

  No

  N/A

Training

• Have all staff involved in administration of medicines undertaken MDS training in last year?

  Yes

  No

  N/A

• Have all staff administering medication had a competency assessment within the last 12 months?

  Yes

  No

  N/A

Conclusions / Actions Needed

• Conclusions and actions needed:

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