Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
1-Medication Stock Count
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1-1 Have you entered the names of the resident's whose medication was counted into the comments box? (This should be a minimum of 10% of residents)
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1-2 Were all medication counts correct? Upload medication count sheet (paper-based MAR) or stock count report (eMAR)
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1-3 Complete stock check of all controlled drugs. Were all controlled drug medication counts correct?
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1-4 Is the Controlled Drug Register completed accurately? (e.g. each drug listed, page numbers correct, each entry completed fully, black ink
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1-5 Is there evidence of a stock check of Controlled Drugs weekly (as a minimum)?
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1-6 For each medication checked was there enough medication to last each resident until the end of the cycle?
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1-7 If you answered no, has the medication now been ordered? (If you answered 'Yes' to the previous question then select n/a for this question
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1-8 Has waste medication been disposed of promptly so there is no build-up or overflow?
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1-9 Does each medication checked have a valid expiry date?
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1-10 If you answered no, has the out-of-date medication now been disposed of appropriately and replacement medication ordered (if required)?
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1-11 Check medication stock levels for any resident(s) that have moved into the home or returned from hospital in the last 7 days. Do they have enough medication to last until the end of the cycle?
2 MAR / eMAR Chart Check
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2-1 Are all MAR / eMAR charts completed accurately? (e.g. up-to-date, no missing signatures) Check the last 7-day eMAR report via the Log My Care dashboard for any alerts that have been identified.
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2-2 Do all MAR / eMAR chart instructions correspond with container instructions? (e.g. label on container precisely matches the instructions on the MAR / eMAR chart, check dosage and strength)
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2-3 Where a medication has not been given is an appropriate code used and explanation written on the back of the MAR or noted within eMAR?
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2-4 Check any residents admitted within the last 7 days. Do they have a medication profile which includes a photo which was taken in the last 12 months and their allergy status?
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2-5 For paper-based MAR charts are the counts on the bottom of each medication completed each day?
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2-6 Review 10% of residents topical administration charts (tMAR's). Are the charts completed as per the frequency prescribed with no gaps?
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2-7 Do all topical medications have clear instructions for use? (e.g. don’t state 'as directed')
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2-8 Review 10% of thickening agents. Is each administration of thickener identified on LOG MY CARE when given by staff?
3 PRN / 'as required' Medication
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3-1 Does each PRN / 'as required' medication for the residents reviewed have a PRN protocol in place?
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3-2 Does each protocol include person-centred details about when to administer the PRN / 'as required' medication? (e.g. how the person demonstrates they are in pain)
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3-3 For each PRN / 'as required' medication administered has the reason for administering been recorded?
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3-4 Is there a PRN / 'as required' protocol in place for any new PRN / 'as required' medications started within the last 7 days? (Please state in comments how many new PRN / 'as required' medications have been started in the last 7 days and given resident initials)
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3-5 Where a PRN / 'as required' medication has a variable dose does the protocol clearly indicate how you would know whether which dose to administer?
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3-6 For PRN / 'as required' medication which has a variable dose (e.g. 1 or 2 tablets) is the number given recorded on the MAR / eMAR?
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3-7 For residents who are prescribed PRN / 'as required' medication for stress and distress, is there evidence that appropriate de-escalation techniques were used prior to administering the medication?
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3-8 Have all PRN / as required protocols for medication used to support residents with stress or distress been reviewed within the last month (or earlier if needs have changed)? (e.g. ensure they are person-centred and describe clearly for that resident when the medication should be used, linked to emotional well-being plan, describe individual's triggers, supportive interventions, specific about when to administer PRN / as required medication)
4 Medication Storage Check
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4-1 Are medication storage areas (e.g. medication trolley, individual medication cupboards) clean and well-organised?
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4-2 Are all medication cupboards and trolleys kept locked?
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4-3 Are all medication trolleys secured to the wall when not in use?
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4-4 Do any residents who have moved into the home / unit within the last 7 days have a photo (no more than 12 months old) on their container within the medication trolly
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4-5 Is all medication held securely in the original container? (e.g. no loose strips of medication)
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4-6 Are internal medications kept separately from external medications?
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4-7 Is the date of opening documented on all topical and liquid medications, including any items held in the medication fridge? (e.g. creams, bottles, eye ointments, ear drops)
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4-8 Is there evidence of a weekly treatment room cleaning schedule in place which includes the medication fridge, cleaning of cupboards, floor and trolley?
5 Control of medication temperature
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5-1 Is the treatment room and medication fridge(s) temperature taken and recorded daily? (e.g. no missing entries)
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5-2 The temperature of the treatment room should be below 25oC. Is each temperature recorded for the last week below this?
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5-3 If you answered 'no' to the previous question, is there evidence that any temperatures above 25oC were escalated and appropriate action was taken?
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5-4 The temperature of the medication fridge must be between 2oC - 8oC. Is each temperature recorded for the last week within this range?
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5-5 If you answered 'no' to the previous questions, is there evidence that any temperatures outside of the desired range were escalated and appropriate actions was taken?
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5-6 Is there a dedicated medicines refrigerator in place? (e.g. no items other than medication are kept in the medication fridge)
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5-7 Is the fridge kept locked?
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5-8 Does each medication within the fridge have a valid expiry date?
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5-9 If you answered no, has the out-of-date medication now been disposed of appropriately and replacement medication ordered (if required)?
