Medicines Management Audit Tool for Children's Homes

Medicines Management

Audit Tool

Children’s Homes

RQIA pharmacy team acknowledge that the audit tool template is not exhaustive but can assist managers and providers of children’s homes to develop their own audit tool to help monitor the management of medicines.

| Name of children’s home | | | | | |
| --- | --- | --- | --- | --- | --- |
| Name of person completing audit | | | | | |
| Date of audit | | | | | |
| Any outstanding issues from last

audit/action plan? | | | | | |
| Action plan produced | | | | | |
| Action plan shared with staff | | | | | |
| Overall action Plan | | | | | |
| | | By who | When | | Date completed |
| 1 | | | | | |
| 2 | | | | | |
| 3 | | | | | |
| 4 | | | | | |
| 5 | | | | | |
| 6 | | | | | |

| Training and competency assessment

• Trained and competent staff undertake the management of medicines.

• Systems are in place to review staff competency in the management of medicines.

• Staff are supported to manage medicines safely. | | |
  | --- | --- | --- |
  | 1 | Records of staff training and competency assessment for medicines management

• How often is training completed?

• How often is competency assessed?

• Is there a staff training matrix?

• Is medicines management training and competency assessment up to date?

• Is the staff signature list up to date?

• Are records available for inspection?
  For additional information please refer to: Minimum Standards for Children’s Homes April 2023

MinimumStandardsforChildren'sHomes2023 | |

Action plan to address issues:

| Governance and audit

• Robust systems are in place to audit all aspects of the management of medicines.

• Robust incident reporting systems are in place to identify, record, report, analyse and learn from incidents and near misses involving medicines and medicinal products.

• Staff are encouraged to report all medication related incidents, including near misses, to drive improvement. | | |
  | --- | --- | --- |
  | 1 | Policies and procedures are up to date and available for staff.

Up to date, subject to regular review and readily available for staff reference.

Read & understood by all staff. | |
| 2 | Audits cover all areas of medicines management, are performed regularly, discrepancies are investigated and records maintained. | |
| 3 | Is the date of opening recorded on all medicines?

Only one supply of each medicine open/in-use at any time? | |
| 4 | Action plan from last in-house audit has been addressed and improvement sustained. | |
| 5 | Last Quality Improvement Plan (RQIA) has been addressed and improvement sustained. | |

| Governance and audit (continued)

• Robust systems are in place to audit all aspects of the management of medicines.

• Robust incident reporting systems are in place to identify, record, report, analyse and learn from incidents and near misses involving medicines and medicinal products.

• Staff are encouraged to report all medication related incidents, including near misses, to drive improvement. | | |
  | --- | --- | --- |
  | 6 | Have medication related incidents have been identified and reported?

How many incidents/near misses have there been since last audit?

Have investigations been completed and the learning shared with staff?

Are there any trends? (out of stocks, missed doses, controlled drug discrepancies) | |
| 7 | Is there good communication with other healthcare professionals?

(during admission process, ordering medicines, reporting non-compliance) | |

Action plan to address issues:

| Controlled drugs

• Controlled drugs are managed in accordance with legislative requirements and the Home’s Standard Operating Procedures | | | | --- | --- | --- | | 1 | Are controlled drugs (CDs) managed and stored in accordance with legislation and the home’s specific Standard Operating Procedures? | | | 2 | Is the CD key held by a designated member of staff?

(If this practice is not followed a risk assessment should be in place) | |
| 3 | Is the CD key held separately from all other keys? | |
| 4 | Are controlled drugs reconciled at each handover of responsibility? Do both staff sign records?

(If this practice is not followed a risk assessment should be in place) | |
| 5 | Is the controlled drug book accurately maintained?

(separate page for each young person and medicine, name, strength and form of each drug accurately recorded at the top of each page, accurate records of prescribing, receipt, administration and disposal) | |
| 6 | Administration: Does a second member of staff witness the administration of controlled drugs and sign the controlled drug record book to confirm that they have been present at time of administration? | |
| 7 | Is the controlled drug audit correct?

Have there been any delayed/omitted doses? | |
| 8 | Disposal:

Are medicines, including controlled drugs, returned to the community pharmacy in a timely manner and records accurately maintained? | |
| Action plan to address issues: | | |
| Medicines storage

• Medicines must be stored securely in accordance with legislation and manufacturers’ requirements.
• It is important that they are stored safely and securely so that there is no unauthorised access and disposed of promptly to ensure that a discontinued medicine is not administered in error. | | | | 1 | Are medicines stored securely?

(Locked cupboard /treatment room, key held by person in charge of medicines on shift)

Is a risk assessment in place if key not held by one designated member of staff? | |
| 2 | Are medicines stored safely in accordance with manufacturers’ instructions?

(Temperature, expiry dates including eye drops, liquids, insulin) | |
| 3 | Medicines requiring cold storage

Max, min and current temperature of refrigerator 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 | Is the date of opening recorded on all medicines?

Only one supply of each medicine open/in-use at any time? | |
| 6 | Infection Prevention and control

(treatment room clean & tidy, measuring cups and oral syringes) | |
| Action plan to address issues: | | |
| Medicine records

• Medicines records should comply with legislative requirements, professional standards and guidelines. Records should provide a clear audit trail – medicines prescribed, ordered, received, administered and transferred/disposed of.
• Personal medication records (kardexes) are used to list all of the prescribed medicines, with details of how and when they should be administered.  It is important that these records accurately reflect the most recent prescription to ensure that medicines are administered as prescribed and because they may be used by other healthcare professionals, for example, at medication reviews or hospital appointments.
• It is important to have a clear record of which medicines have been administered to young people to ensure that they are receiving the correct prescribed treatment. | | | | 1 | Records of medicines orders | | | 2 | Records of incoming medicines

(including those supplied on admission, antibiotics, ordered by staff) | |
| 3 | Personal medication record/kardex accurately written; verified and signed by two staff

Includes date of writing, date of birth, allergy status and photograph (consent)

Obsolete kardexes cancelled and archived i.e. only one kardex available for each young person

Check each personal medication record | |
| 4 | Medication administration records are accurately maintained and include day, month and year of administration

• Are there any missed signatures?
• Is the reason for any omitted doses accurately recorded e.g. refusal, young person unavailable in the home etc.?
• Is regular refusal referred to the prescriber and a record of their advice maintained? | |

| Medicine records (continued)

• Medicines records should comply with legislative requirements, professional standards and guidelines. They should provide a clear audit trail – medicines ordered, received, prescribed, administered and transferred/disposed of.
• Personal medication records (kardexes) are used to list all of the prescribed medicines, with details of how and when they should be administered.  It is important that these records accurately reflect the most recent prescription to ensure that medicines are administered as prescribed and because they may be used by other healthcare professionals, for example, at medication reviews or hospital appointments.
• It is important to have a clear record of which medicines have been administered to young people to ensure that they are receiving the correct prescribed treatment. | | | | --- | --- | --- | | 5 | Records of out-going medicines

(discharge, home leave)

(date, quantity, signature/s of staff and recipient) | |
| 6 | Records of disposal

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

Action plan to address issues:

| Stock management

• Medicines must be available for administration as prescribed.
• Medicines stock levels must be checked on a regular basis and new stock must be ordered on time.
• This ensures that the young person’s medicines are available for administration as prescribed. | | | | --- | --- | --- | | 1 | Systems in place to ensure all young people have a continuous supply of their prescribed medicines

(Trigger in place to highlight low stock levels/potential out of stocks) | |
| 2 | Have there been 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 | Have discontinued medicines been returned to the community pharmacy for disposal and records accurately maintained? | |

Action plan to address issues:

| Compliance

• Compliance with prescribed medication regimens is monitored and any omissions or refusals likely to have an adverse effect on the child or young person’s health are reported to the person with parental responsibility and the prescriber.
• When a young person does not take their medicines as prescribed this has the potential to affect their health and well-being.

• Staff must be able to show that the medicines were offered and the young person was encouraged to take their medicines. The prescriber must be made aware of any compliance issues so that the young person’s medicines can be reviewed and changes made if necessary. | | | |
  | --- | --- | --- | --- |
  | 1 | Have any medicines been omitted because a young person refused? | | |
  | 2 | Have any medicines been omitted because a young person was unavailable in the home? | | |
  | 3 | Has the reason for any omitted doses been recorded on all occasions? | | |
  | 4 | Has the prescriber been made aware of all compliance issues (including missed antibiotic doses, oral contraceptives)? | | |
  | 5 | Is there a record of the advice provided by the prescriber on how to manage compliance issues for each young person who has refused their medicines/been unavailable in the home? | | |
  | 6 | Is a care plan in place detailing how each young person likes to take their medicines to assist compliance? | | |
  | Action plan to address issues: | | | |
  | Self-administration

• Children and young people are enabled to self-administer their medicines where the risks have been assessed and it is deemed safe and appropriate. | | | |
  | 1 | Do any young people self-administer some/all of their medicines?

Has the decision making process been comprehensively documented in the young person’s care plan and the information shared with all relevant professionals?

Has the young person signed an agreement confirming that they will take their medicines correctly and store their medicines appropriately so as not to place any other young person at risk? | | |
| 2 | Which medicines are self-administered? | | |
| 3 | Does the young person’s personal medication record (kardex) indicate which medicines are being self-administered? | | |
| 4 | Is a record of ordering, receipt and transfer to the young person maintained? | | |
| 5 | Do staff monitor compliance on a regular basis and review competence to self- administer as necessary? | | |
| 6 | Is suitable storage available for the young person?

Is a personal lockable storage space available to store medicines, the key being held by the child or young person? Is the safe custody of a spare key the responsibility of the registered manager? | | |
| Action plan to address issues: | | | |
| New admission, Re-admission, Respite

• Young people who use medicines may follow a pathway of care that can involve both health and social care services.  It is important that medicines are not considered in isolation, but as an integral part of the pathway, and at each step.  Problems with the supply of medicines and how information is transferred put young people at increased risk of harm when they change from one healthcare setting to another.
• Systems must be in place to ensure the safe management of medicines when a child or young person arrives at or leaves the home. Staff ensure that medicines are administered in accordance with the young person’s most recent prescription. | | | | | | | Young person’s initials | Young person’s initials | | 1 | Written confirmation of current medicines regimen

(a list provided by the GP or a hospital discharge letter)

(A kardex from last placement/family is not sufficient as this may be incorrect) | | |
| 2 | The hospital discharge letter (if applicable) has been forwarded to the young person’s GP and a copy retained in young person’s notes. | | |
| 3 | Any discrepancies between the GP list & medicines supplied by family/other placement is followed up prior to administration of any medicines. | | |
| 4 | Personal medication record (Kardex) accurately written; verified and signed by two staff

Includes: date of writing, date of birth, allergy status and photograph | | |
| 5 | Accurate record of all medicines received

(Name, strength, quantity, date, staff signature/s) | | |
| 6 | Medicines available for administration

(Are there any missed doses/delayed doses due to out of stocks?) | | |
| 7 | Medicines available at beginning of next medication cycle | | |
| 8 | Discontinued medicines

(Discontinued on Kardex, Removed from trolley and overstock cupboard & Returned to pharmacy) | | |
| 9 | When the young person leaves the home written confirmation of current medication regimens is sent with them by the person in charge of the home.

Leaving in this context includes moving to another home or care setting or leaving the care system. | | |

Action plan to address any issues:

| Antibiotics

• Antibiotics must be commenced without delay and administered as prescribed to ensure that the infection is treated appropriately and to reduce the likelihood of antibiotic resistance.
• Any non-compliance must be referred to the prescriber for guidance. | | | | | --- | --- | --- | --- | | | | Young person’s initials | Young person’s initials | | 1 | Date young person seen by GP/ prescription issued | | | | 2 | Date medication dispensed | | | | 3 | Date medication commenced

(Dates for 1, 2 & 3 should be the same so there is no delay) | | |
| 4 | Audit correct – no delayed/omitted doses | | |
| 5 | Written confirmation of medicines i.e. a copy of the prescription, hospital discharge letter, system in place for telephoned directions | | |
| 6 | Personal medication record/kardex accurately updated; verified and signed by two staff

(includes date of prescribing) | | |
| 7 | Medicines accurately received

(name, strength, quantity, date) | | |
| 8 | Guidance sought from GP/dentist if young person refuses antibiotic | | |

Action plan to address issues:

| Distressed reactions

• Young people **** will sometimes get distressed and will occasionally require medicines to help them manage their distress.  It is important that care plans are in place to direct staff when it is appropriate to administer these medicines and that records are kept of when the medicine was given, the reason it was given and what the outcome was.
• If staff record the reason and outcome of giving the medicine, then they can identify common triggers which may cause the young person’s distress and determine if the prescribed medicine is effective for the young person.
• The use of these medicines is considered to be a restrictive practice. ** | | | | | | | --- | --- | --- | --- | --- | --- | | Young person | Personal medication record/kardex | | Care plan | Daily notes / reason/outcome sheets maintained | | | | Name(s) of medicine | Parameters for administration | Yes/No | Dates administered | Match daily notes/reason and outcome sheets | | Action plan to address issues: | | | | | |

| Home remedies/non-prescribed medicines

• Systems are in place for non-prescribed medicines (home remedies) to ensure they are managed in accordance with qualified medical, nursing or pharmaceutical advice. | | | | --- | --- | --- | | 1 | An up to date policy is in place for the use of non-prescribed medicines. | | | 2 | Stock correlates with the home’s policy, is stored securely and is in-date.

(where more than one paracetamol product is available this clearly highlighted?

are doses appropriate for age group?) | |
| 3 | Records of administration are accurately maintained. | |

Action plan to address issues:

| Additional care plans (when necessary) | | |
| --- | --- | --- |
| 1 | Pain management | |
| 2 | Time - critical medicines e.g. insulin, epilepsy | |
| 3 | Covert administration

The act of administering medication in disguised or covert form is discouraged but, when necessary, it is undertaken in accordance with professional advice and guidelines and as part of a decision making process which is documented in the child or young person’s care plan. | |
| 4 | Use of unlicensed medicines and licensed medicines used outside of the terms of the product license (off-label) | |

Action plan to address issues:

Reference Sources:

Department of Health Minimum Standards for Children’s Home April 2023:

MinimumStandardsforChildren'sHomes2023

RQIA Provider Guidance _ Medicine Notifications _ 2223

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RQIA – Children’s Home – Audit Tool – September 2025