Medication audits in care homes

Care home providers continuously review their medicine management practices to ensure the safety of service users. This process includes monthly medication audits as part of the provider’s governance framework. The following areas are regularly highlighted in Care Quality Commission (CQC) inspections and should be included in these audits to ensure they are robust and fit for purpose.

Controlled drugs

The audit should note evidence of weekly stocktaking for controlled drugs. The register should have two staff signatures that can be cross-referenced with the staff signature list. All controlled drugs must be stored appropriately in a locked cabinet in a locked room, with keys kept separately from other medication keys.

Homely remedies

Homely remedies include over-the-counter medications that care homes may use to treat minor ailments and self-limiting conditions, such as mild to moderate pain, heartburn, constipation, and diarrhoea. Care homes should include a process for safely using homely remedies in their medicine management policy. This includes written agreements for each resident to use homely remedies, signed by a healthcare professional (such as a GP or pharmacist) who has advised on their use. In addition, auditing should determine whether homely remedies are stored correctly and in date and whether each dose has been documented with the reason for administration.

Medication administration record (MAR) charts

Audits should check that all MAR charts are completed with no gaps – including using the correct refusal codes (when relevant). PRN medications should be checked alongside their administration protocol and record. A robust audit will also identify any patterns, such as refusals, missed signatures, or omissions.

Medication policy

This policy and procedure should be reviewed yearly, updated as required, and signed and dated to evidence the review. Monthly audits should be updated following any policy revisions.

PRN medications

Audits should check that PRN medications have an administration protocol and record as part of the MAR. This allows the provider to review administrations and identify if and when a referral to a GP or other healthcare professional is needed, such as if prescribed pain relief is ineffective.

Stock management

Stock management is essential to mitigating medicine management risks. For example, if sufficient stock is already held, additional PRN medications should not be ordered. Medications for residents no longer at the services should be destroyed or returned as per the service’s medication policy – and this should be included in the audit.

Waste management

The audit should consider whether appropriate waste management methods are used for medications and sharps, including their proper storage while they await collection. In nursing services, this will include the destruction of medication; in residential services, it will include the return of excess or unwanted stock to the dispensing pharmacist.

When it comes to medication policies and audits, we know what it takes to ensure service user safety and regulatory compliance. We offer comprehensive and up-to-date policies and procedures for England (CQC), Scotland (Care Inspectorate), and Wales (Care Inspectorate Wales). We also offer various compliance services, such as mock inspections and compliance audits. Our auditors are experienced adult social care professionals with many years of experience in the sector, delivering practical advice and guidance on service improvement. Contact us today on 01305 767104 to learn how we can support your social care business.

For more information on Medication audits in care homes talk to W&P Compliance Centre