Medicines optimisation

If the service provides medication support, is there a clear, accurate medication care plan specifying the level of support required?

What we look for: Check if the plan states exactly what staff must do (e.g., administer, prompt, assist). Good looks like clear instructions on times, routes, and specific PRN protocols. Fails if the level of support is ambiguous or contradicts the MAR chart.

Evidence: Medication care plan, PRN protocols, MAR charts, pharmacy letters

Is there a robust system for annual and post-incident medication administration competency assessments?

What we look for: Review the competency tracking matrix and sample 3 individual staff files. Good looks like annual observational sign-offs in the community, plus ad-hoc checks following any medication errors. A fail is relying solely on Q&A without practical observation, or expired assessments.

Evidence: Medication competency assessment forms, MAR chart audit follow-ups, staff training matrix

Where care plans specify medication support, are daily logs aligned with MAR charts to confirm completion or refusal?

What we look for: Check logs for service users receiving medication support. Good looks like daily notes explicitly mentioning medication administration/prompts, matching the signatures on the MAR. A fail is discrepancies between the daily log narrative and the MAR chart.

Evidence: Daily logs, MAR charts, medication care plans

Is a full medicines reconciliation completed immediately following hospital discharge to ensure safe administration of new or altered prescriptions?

What we look for: Review the MAR charts and discharge notes for recently discharged people. Check that new medications are accurately transcribed, stopped meds are removed, and staff are clear on changes. A fail is an active MAR that contradicts the hospital discharge prescription.

Evidence: Hospital discharge summaries (TTOs), New MAR charts, Pharmacy correspondence, Medicine risk assessments

Have late or shortened visits impacted the safe administration of time-critical medicines (e.g., insulin, Parkinson's medication)?

What we look for: Identify clients on time-critical medicines. Compare their prescribed medication times with actual arrival/departure times on the ECM system. A fail is medication given outside the safe window due to poor timekeeping without clinical consultation.

Evidence: MAR charts, ECM logs cross-referenced with medication times, Incident reports

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

Do staff files contain documented evidence of a face-to-face practical medication competency assessment completed in the field?

What we look for: Check that competency was assessed by direct observation in a service user's home, not just via a quiz or roleplay in the office. Good looks like a detailed checklist covering preparation, administration, and recording.

Evidence: Practical competency assessment forms, Field observation notes, Assessor sign-offs

Does the competency assessment specifically evaluate staff understanding and practice regarding the safe administration of 'as required' (PRN) medicines?

What we look for: Review the standard competency template. It must include checks on whether staff check when PRN was last given, understand the gap between doses, and document the reason/outcome of administration.

Evidence: Competency assessment templates, PRN protocols, Completed assessment forms

Do spot checks on recent MAR charts confirm that staff who recently passed their competency assessment are practicing safely and accurately?

What we look for: Sample MAR charts filled in by staff who passed their competency in the last month. Look for missing signatures or incorrect coding to ensure the competency assessment accurately reflects real-world practice.

Evidence: Completed MAR charts, Audit action plans, Care worker daily notes

Where medication support is required, are safe systems established immediately, including accurate MAR charts and clear instructions?

What we look for: For any new user requiring medication support, audit the medication setup. Check that MAR charts are populated accurately against a pharmacy list or prescription, and that specific instructions (e.g., PRN protocols) are active from day 1. Any ambiguity in medication instructions upon onboarding is a critical fail.

Evidence: Medication care plans, MAR (Medication Administration Record) charts, pharmacy printouts, PRN protocols.

Is a documented medication competency assessment completed in the field before the staff member administers medication alone?

What we look for: Check if a manager or senior has directly observed the new starter administering medication in a person's home. Passing this check requires a signed, dated, and detailed competency form on file prior to them acting independently.

Evidence: Medication competency assessments, spot check forms, MAR chart signatures

Are topical medicines and barrier creams applied according to instructions and recorded accurately on topical MAR (TMAR) charts?

What we look for: Check TMARs and body maps. Good looks like staff signing TMARs correctly and following body maps that indicate where creams should be applied. A fail is missing TMARs or using prescribed creams for general moisturising without instruction.

Evidence: TMAR charts, MAR charts, Body maps

Are staff directly observed administering medicines, with supervisors checking MAR chart completion and adherence to the 6 Rs?

What we look for: Examine spot checks for visits involving medication support. The supervisor must observe the carer checking the MAR, preparing the medication, offering it, and signing correctly. Missing observations of these critical safety steps would be a fail.

Evidence: Spot check records, medication competency assessments, MAR charts