Care home medicines audit checklist

Source anchors

How to use this checklist

This is the care home (adult social care) version of the medicines checklist. It assumes the home administers medicines prescribed by a GP or other prescriber and holds stock including controlled drugs. It does not cover prescribing or Patient Group Directions, which belong to the primary care version.

Use it to audit whether the home can show safe medicines management: support and consent, ordering and storage, administration and recording, controlled drugs, homely remedies, antimicrobials and pain, and pharmacist review and audit. Use it monthly, after a medicines incident, before a governance review, or before an inspection-readiness review.

Medicines arrangements vary. Check the current legal, professional, pharmacy and product-specific requirements that apply to the home before relying on local defaults.

For each row, record:

Met: evidence is current and complete.
Part met: evidence exists but has a gap or needs follow-up.
Not met: evidence is absent or the control is not working.
Not applicable: the home does not carry out this activity.

Every Part met or Not met item should create an action with an owner and due date.

Service details

Field	Local entry
Service name
Location
Date completed
Completed by
Registered Manager
Medicines Lead
Period reviewed

1. Roles, scope and competence

Check	Evidence to review	Status	Action owner	Due date
A Medicines Lead and a deputy are named.	Role list, procedure, rota.
Staff only administer medicines they are trained and assessed competent to give, including specific competence for controlled drugs, covert administration and time-sensitive medicines.	Training matrix, competency assessment.
Specific clinical tasks (for example insulin, thickeners, PEG, oxygen) have their own competence evidence where the home does them.	Competency record, procedure.
The supplying pharmacy and residents' GP practice(s) are the named medicines advice route.	Advice record, contact route, pharmacy agreement.
The home knows its controlled-drug oversight route: a care home is not a designated body that appoints its own Controlled Drugs Accountable Officer, so it knows the NHS England Accountable Officer and Local Intelligence Network for its area and reports controlled-drug concerns through it.	Procedure, local CD contact details, incident-reporting route.

2. Support, consent and review

Check	Evidence to review	Status	Action owner	Due date
Each resident's level of medicines support is assessed and recorded (prompt, assist or administer).	Care plan, medicines assessment.
Capacity and best-interest decisions about medicines are recorded where relevant.	MCA record, best-interest note.
Self-administration is offered where appropriate, risk assessed, and supported with secure storage in the resident's room.	Self-administration assessment, storage check.
Medicines are reconciled on admission, on hospital transfer and discharge, and at any change.	Reconciliation record, discharge note, pharmacy query.
Residents have access to a structured medication review and the home acts on its recommendations.	Review record, action evidence.

3. Ordering, receipt and storage

Check	Evidence to review	Status	Action owner	Due date
Medicines are ordered and received through the supplying pharmacy with dated receipt records.	Order log, receipt record.
Medicines are stored securely and at the correct temperature.	Storage check, room and trolley audit.
Fridge medicines have daily minimum and maximum temperature records with escalation when out of range.	Fridge log, incident record.
Controlled drugs that need safe custody are stored in a controlled-drugs cupboard meeting the Misuse of Drugs (Safe Custody) Regulations 1973.	Cupboard check, storage procedure.
Expiry and stock are checked and acted on; returns and disposal are recorded.	Expiry audit, returns and disposal log.

4. Administration and recording

Check	Evidence to review	Status	Action owner	Due date
The medicines administration record (MAR) is completed at the time of administration.	MAR sample, audit record.
Omissions, refusals and unavailable medicines are recorded with a reason and a follow-up action.	MAR sample, incident or follow-up note.
PRN (when required) medicines have a current protocol: what for, dose, frequency, maximum in 24 hours, and what to do if it does not work.	PRN protocol, MAR, care plan.
Covert administration is used only after a recorded best-interest meeting with the prescriber, pharmacist and the resident's representative, with a covert administration plan that is reviewed regularly.	Best-interest record, covert plan, pharmacist advice.
Time-sensitive medicines (for example Parkinson's medicines) are given within their time window, and crushing or disguising medicines follows pharmacist advice.	MAR timing audit, pharmacist advice.

5. Controlled drugs

Check	Evidence to review	Status	Action owner	Due date
A controlled-drugs register records receipt, administration and disposal with a running balance.	CD register.
Administration of a controlled drug is witnessed: the administering staff member and a trained witness both sign the CD register, and the administering staff member signs the MAR.	CD register, MAR.
Running-balance checks are done at a stated frequency (commonly each shift handover).	CD balance-check record.
Discrepancies are investigated and escalated the same day.	Discrepancy record, escalation note.
Disposal or denaturing of controlled drugs is recorded and witnessed by an authorised person, using a denaturing kit.	Disposal record, denaturing kit log.

6. Homely remedies and self-care

Check	Evidence to review	Status	Action owner	Due date
The home has a homely remedies policy agreed with the GP or pharmacist, listing each over-the-counter medicine, what it is for, the dose, and residents who must not have it.	Homely remedies policy, GP or pharmacist sign-off.
A homely remedy is given for a limited time only before seeking advice (a common limit is 48 hours, or 24 hours for diarrhoea).	Homely remedies policy, MAR.
Each dose of a homely remedy is recorded on the resident's MAR.	MAR sample.
Staff are trained and competent to support self-care with over-the-counter products.	Training matrix, competency record.

7. Antimicrobials and pain

Check	Evidence to review	Status	Action owner	Due date
Antibiotics are given as prescribed and the course is completed unless the prescriber advises otherwise; antimicrobial use links to the home's infection prevention and control work.	MAR, IPC link, antimicrobial guidance.
A suspected infection is escalated appropriately rather than an antibiotic assumed.	Escalation tool, GP contact record.
Pain is assessed for every resident, including a recognised observational tool for residents who cannot reliably self-report (for example people living with dementia).	Pain assessment, care plan.
PRN pain relief has a protocol, its effect is recorded and reviewed, and persistent or escalating pain is referred.	PRN protocol, MAR, review note.

8. Incidents, audit and governance

Check	Evidence to review	Status	Action owner	Due date
Medicines errors and near misses are reported, reviewed for themes, and learning is shared.	Incident sample, medicines theme report.
Harm, duty of candour, safeguarding and CQC statutory notification decisions are considered.	Linked records, decision notes.
A pharmacist-led or pharmacy-supported medicines audit runs at a stated cadence and covers records, storage, expiry, controlled drugs, covert administration and competence.	Audit schedule, completed audits.
Actions from medicines audits and incidents have owners, due dates and completion evidence.	Improvement actions, evidence.
Medicines risks are on the risk register, and the Registered Manager reviews medicines themes and overdue actions.	Risk register, governance minutes.

9. Summary judgement

Question	Answer
Which medicines process carries the highest current risk?
Which medicines record has the weakest evidence trail?
Which omission, refusal or error theme repeated in the last 12 months?
Which action or audit finding is overdue?
What would a CQC inspector see if they asked for medicines evidence today?

10. Action log

Action	Source check	Owner	Due date	Completion evidence

11. Completion

Sign-off	Name	Date
Completed by
Reviewed by Registered Manager

This checklist is a working tool. It does not replace live regulator guidance, professional advice, pharmacy advice, product-specific requirements, controlled-drug legal advice or clinical judgement.