RQIA Medicines Management Audit Tool for Care Homes

Medicines Management Audit Tool

RQIA pharmacy team developed this medicines management audit tool template in collaboration with a number of care homes. RQIA acknowledge that the audit tool template is not exhaustive but can assist managers and providers to develop their own audit tools.

Name of home
Date of audit
Name of person completing audit
Time taken to complete the audit
Action plan produced
Action plan shared with staff
Previous action plan completed

Overall action Plan
		By who	When	Date completed

New admission, Re-admission, Respite
		Resident’s initials	Resident’s initials
1	Written confirmation of medicines

Hospital discharge letter/ GP printout | | |
| 2 | Copy of discharge letter forwarded to GP

Copy retained in resident’s notes | | |
| 3 | Personal medication record (PMR) accurately written; verified and signed by two staff

Includes date of writing, date of birth, allergy status and photograph | | |
| 4 | Hand-written medication administration record (MAR) record accurately written and verified and signed by two staff

Includes day, month and year of administration | | |
| 5 | Medicines accurately received

(Either on MAR sheet or home’s separate recording book) | | |
| 6 | Medicines available for administration

(Any missed doses due to out of stocks, sufficient medicines supplied for period of respite care) | | |
| 7 | Medicines available at beginning of next medication cycle | | |
| 8 | Discontinued medicines

Removed from PMR, MAR, trolley and overstock cupboard. Pharmacy informed (not re-ordered or re-started in error at new medication cycle) | | |

Action plan to address issues:

Antibiotic
		Resident’s initials	Resident’s initials
1	Date service user seen by GP/ Prescription issued
2	Date medication dispensed
3	Date medication commenced
4	Audit correct – no delayed/omitted doses
5	Prophylactic antibiotic on hold (if applicable)
6	Written confirmation of medicines i.e. copy of the prescription, hospital discharge letter, system in place for telephoned directions
7	Personal medication record (PMR) accurately updated; verified and signed by two staff

(includes date of prescribing) | | |
| 8 | Hand-written medication administration record (MAR) record accurately written and verified and signed by two staff

(includes day, month and year of administration) | | |
| 9 | Medicines accurately received

(Either on MAR sheet or home’s separate recording book) | | |

Action plan to address issues:

Controlled drugs
1	Controlled drugs managed and stored in accordance with legislation and the home’s specific Standard Operating Procedures.
2	Key held by designated member of staff.

Key held separately from all other keys. | |
| 3 | Controlled drugs reconciled at each handover of responsibility. Records signed by both staff. | |
| 4 | Controlled drug book accurately maintained.

(separate page for each resident, name, strength and form of each drug accurately recorded at the top of each page, accurate records of receipt, administration and disposal) | |
| 5 | Administration:

A second member of staff witnesses the administration of controlled drug and signs the controlled drug record book to confirm. | |
| 6 | Audit correct – no delayed/omitted doses | |
| 5 | Disposal:

Medicines disposed of in a timely manner and records accurately maintained.

Residential homes – return to pharmacy

Nursing homes – denature all controlled drugs in Schedules 2, 3 and 4 Part (1) prior to disposal | |

Action plan to address issues:

Medicine records
1	Medicines orders
2	Incoming medicines

(monthly, new resident, medicine changes, acute medicines (antibiotic)) | |
| 3 | Personal medication record (PMR) accurately written; verified and signed by two staff

Includes date of writing, date of birth, allergy status and photograph

Obsolete cancelled and archived | |
| 4 | Hand-written medication administration record (MAR) record accurately written and verified and signed by two staff

Includes day, month and year of administration Personal medication records | |
| 5 | Out-going medicines

(discharge, home leave) | |
| 6 | Records of disposal

(date, signature/s of staff and pharmacist) | |

Action plan to address issues:

Stock management
1	Systems in place to ensure all residents have a continuous supply of their prescribed medicines

(Trigger in place to highlight low stock levels/potential out of stocks) | |
| 2 | Any missed doses due to stock supply issues?

(Evidence of action taken by staff to obtain medicines) | |
| 3 | Is there a trend of medicines being out of stock?

(How many medicines have been out of stock this month?) | |
| 4 | Have missed doses been reported appropriately?

(GP, pharmacist, care manager, family, RQIA – will depend on medication and number of omitted doses) | |
| 5 | Any missed doses from compliance aids i.e. MDS, Pillpac (look through blister packs/Pillpac to ensure that reason for any omissions accurately recorded or has an error occurred) | |

Action plan to address issues:

Warfarin
Resident	Written confirmation of warfarin regime	Obsolete records cancelled and archived	Care plan	Transcribing involves two staff	Daily stock balance	Audit correct
Action plan to address issues:

Distressed reactions
Resident	PMR		Care plan	Daily notes / reason/outcome sheets maintained
	Name(s) of medicine	Parameters for administration	Yes/No	MAR entries	Match daily notes/reason and outcome sheets
Action plan to address issues:

Pain management
Resident	PMR		Care plan		Evaluation of pain control	Pain tool
	Name(s) of medicine	Parameters for administration	In place	Frequency of evaluation	Frequency	(where appropriate/ DE/LD)
Action plan to address issues:

Thickening agents
Resident	Personal medication record (PMR)		Administration Records	SALT report		Care plan
	PMR	Level

1,2,3 | Level

1,2,3 | Level

1,2,3 | Up to date | Y/N | Level

1,2,3 |
| Action plan to address issues: | | | | | | | |

Additional care plans
1	Covert administration
2	Crushing medicines, adding to food/drinks
2	Self-administration
3	Compliance
4	Critical medicines – insulin, warfarin, Parkinson’s, rectal diazepam, buccal midazolam, anticipatory medicines

Action plan to address issues:

Medicines storage
1	Medicines stored securely

(Locked treatment room, trolleys and cupboards. Key held by person in charge of medicines on shift) | |
| 2 | Medicines stored safely in accordance with manufacturers’ instructions.

(Temperature and expiry e.g. eye drops, liquids, insulin) | |
| 3 | Refrigerated medicines

Max, min and current temperature monitored each day and thermometer then reset.

Temperature between 2 o C and 8 o C.

Action taken if temperature outside this range | |
| 4 | Room temperature monitored daily – at or below 25 o C. | |
| 5 | Thickening agents and nutritional supplements stored securely, under direct supervision of trained staff. | |
| 6 | Oxygen stored securely and signage in place.

(masks – appropriate use and storage) | |
| 7 | Infection Prevention and control

(oxygen masks, aero chambers, measuring cups and oral syringes) | |

Action plan to address issues:

Governance and audit
1	Policies and procedures are up to date and available for staff.
2	Action plan from last audit addressed and improvement sustained.
3	Last QIP addressed and improvement sustained
3	Medication related incidents identified and reported.

Discussed with staff

Any trends? (out of stocks, missed doses at night) | |
| 4 | Good communication with other healthcare professionals

(during admission process, ordering medicines, diabetes nurses, issues getting through to surgery) | |

Action plan to address issues:

Training and competency assessment
1	Records of staff training and competency assessment for medicines management

(Up to date) | | |
| 2 | Records of staff training and competency assessment for any staff completing delegated tasks

(Creams, thickening agents (mandatory training for ALL staff involved)) | | |

Action plan to address issues:

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