Medication / MAR Audit

Is there an up-to-date medication risk assessment detailing the exact level of support required (e.g., prompt, assist, administer)?

What we look for: Review medication care plans and risk assessments. Good looks like a clear distinction between prompting, assisting, and administering, with environmental risks and swallowing difficulties addressed. It is a fail if the level of support is contradictory across documents.

Evidence: Medication risk assessments, care plans, consent forms

Are medication errors and near misses consistently reported, investigated, and analysed to identify trends and prevent recurrence?

What we look for: Examine the incident log for medication errors. Good practice shows thorough investigation, retraining/supervision for the staff involved, and sharing lessons learned with the wider team. A fail is seeing repeat errors by the same staff member with no documented intervention.

Evidence: Incident logs, medication error reports, investigation records, team meeting minutes

Are medication administration records (MARs or eMARs) fully completed without unexplained gaps, showing correct codes where medication was not given?

What we look for: Sample at least 10% of active MAR charts from the previous cycle. Good looks like zero blanks; every entry must have a signature or an appropriate non-administration code (e.g., refused) with a corresponding note. A fail is any unexplained gap or use of Tipp-Ex.

Evidence: Paper MAR charts, eMAR records, daily care notes, communication logs

Do all 'as required' (PRN) medications have a clear, person-centred protocol, and are reasons and outcomes recorded when administered?

What we look for: Check files of people prescribed PRN medication (e.g., pain relief, inhalers). Good looks like a detailed protocol stating what the medication is for, signs of need, max dose, and when to call GP. Fails include missing protocols or staff not recording the outcome of giving the PRN.

Evidence: PRN protocols, MAR charts, daily care notes

Are time-critical medications (e.g., for Parkinson's or diabetes) clearly identified and administered at the exact required times?

What we look for: Identify service users on time-critical medicines. Cross-reference the logged call times and administration times against the prescribed time. Good looks like administration within 30 minutes of the prescribed time. Late or missed doses without escalating represent a failure.

Evidence: MAR charts, medication care plans, call time logs vs administration times

Are topical medicines and prescribed creams recorded accurately on a body map and Topical MAR (TMAR) by care staff?

What we look for: Sample records of people prescribed creams. Good looks like a clear body map indicating where each specific cream goes, matched with a TMAR signed by staff after application. Fails involve staff signing the main MAR but ignoring the TMAR, or applying cream without a body map instruction.

Evidence: TMARs, body maps, daily care notes, medication care plans

Have all staff administering medication completed up-to-date medication training and an annual practical competency assessment?

What we look for: Sample 5 staff members who administer meds. Good looks like valid training certificates and a recently completed, signed, in-person competency check by a qualified supervisor. A fail is allowing staff to administer medication prior to passing their practical competency check.

Evidence: Training matrix, staff personnel files, medication competency observation forms

Are completed MAR charts returned to the office promptly at the end of the cycle and audited by management to drive improvement?

What we look for: Look at the service's own monthly MAR audit process. Good looks like all paper MARs returned within 3 days of cycle end, audited for errors, with a clear action plan generated for any missing signatures. A fail is a backlog of unaudited MAR charts in the office.

Evidence: Returned MAR charts, previous MAR audit records, quality assurance action plans