Survelix CQC Compliance Resource
Medicines Management Monthly Audit Tool
Monthly audit framework for adult social care medicines management
About this audit
This audit is designed to identify medicines management failures before they are found at CQC inspection. It is based on findings from Inadequate and Requires Improvement inspection reports published between 2021 and 2024. Medicines failures are cited in over 60% of Inadequate ratings. Use this tool monthly. Carry forward all NC items to an action plan reviewed at the next governance meeting. Authored by Cheta Ikemsinachi Ogbuzuru.
Improper storage is one of the most frequently cited medicines failures at inspection. Common issues: unlocked cabinets, cabinets in areas accessible to service users, temperature logs not maintained, and medicines for deceased or discharged residents still held on the premises.
| # | Audit Item | Pass / Fail | Finding / Comment | Action Required |
|---|---|---|---|---|
| A1 | All medicines cabinets are locked when not in use and the key is held by a named staff member on duty | |||
| A2 | Medicines storage areas are accessible only to authorised staff. No service users have access to the medicines area | |||
| A3 | Refrigerated medicines (insulin, eye drops, creams) are stored in a locked medicines fridge. Temperature is within 2-8 degrees Celsius | |||
| A4 | Temperature logs are completed twice daily. Any out-of-range readings have been investigated and documented | |||
| A5 | Medicines for service users who have died, been discharged, or transferred are disposed of or returned to pharmacy within 7 days. Records of disposal are retained | |||
| A6 | No medicines are stored in service users' rooms unless a risk assessment supports this and written consent has been obtained | |||
| A7 | Medicines are stored in the original dispensed packaging with the pharmacist label intact. No medicines are stored loose or decanted without a written protocol | |||
| A8 | Controlled Drugs (CDs) are stored in a locked metal cabinet that is fixed to the wall. The cabinet key is held by a registered nurse or trained senior staff member | |||
| A9 | External medicines (for collection by district nurses or community teams) are segregated and clearly labelled. Handover records are completed | |||
| A10 | Medicines due for disposal are segregated from in-use medicines and recorded on the disposal log pending collection or return |
MAR (Medicines Administration Record) chart failures are cited in the majority of Inadequate medicines findings. Inspectors look for gaps, unsigned entries, illegible writing, and lack of guidance for variable-dose or PRN medicines.
Sample selection
Select 5 MAR charts at random. Include at least one for a service user who takes controlled drugs and one for a service user with PRN medicines. Record the service user initials (not names) for audit trail purposes.
| # | MAR Chart Audit Criterion | Chart 1 | Chart 2 | Chart 3 | Chart 4 | Chart 5 | Action |
|---|---|---|---|---|---|---|---|
| B1 | Service user's full name, DOB, and allergy status are recorded on every sheet | ||||||
| B2 | All medicines listed are currently prescribed by a GP or specialist. No medicines listed without a current prescription | ||||||
| B3 | No unexplained gaps in the last 28 days. Every omission has a code applied (see key) and a staff signature | ||||||
| B4 | All administered doses are signed by the administering staff member in the correct box | ||||||
| B5 | No pencil entries. All entries are in permanent ink. No correction fluid is used | ||||||
| B6 | PRN medicines have a corresponding protocol attached or referenced. The protocol includes indication, maximum dose, and review date | ||||||
| B7 | PRN administration episodes record: time, dose given, reason for administration, and outcome observed | ||||||
| B8 | Variable doses (e.g. warfarin) show the actual dose given, not just the medicine name. INR results are referenced where relevant | ||||||
| B9 | Topical medicines (creams, patches, eye drops) note the administration site and frequency | ||||||
| B10 | The MAR chart carries forward accurately from the previous month. No medicines have been omitted during transfer |
Service user initials: Chart 1: ___ Chart 2: ___ Chart 3: ___ Chart 4: ___ Chart 5: ___
CD discrepancies are always a serious finding and may trigger a full CQC investigation. Inspect every CD register entry against the physical stock. Discrepancies must be investigated and reported immediately.
| # | CD Audit Item | Pass / Fail | Finding / Comment / Discrepancy Detail |
|---|---|---|---|
| C1 | CD register entries are in permanent ink. No overwriting, correction fluid, or pencil entries are present | ||
| C2 | Every entry is signed by the administering nurse/trained staff member and witnessed by a second person. Both signatures are legible | ||
| C3 | Running balance is correct for every entry. Physical count matches the documented balance for all CDs held | ||
| C4 | Receipts from pharmacy are recorded in the register on the day of receipt with the pharmacist's delivery note referenced | ||
| C5 | Disposal entries are signed by two staff. Reason for disposal (returned, destroyed) is documented. Volume disposed matches the register | ||
| C6 | No CDs have been in the cabinet beyond their expiry date. Expiry dates are checked at each balance count | ||
| C7 | A balance count is carried out and signed at every nursing handover or at minimum once per shift. Evidence of this is visible in the register | ||
| C8 | Any previous discrepancy has been investigated, documented, and (where appropriate) reported to the pharmacist, CQC, and safeguarding |
| # | Competency Check Item | Pass / Fail | Action / Comment |
|---|---|---|---|
| D1 | All staff administering medicines hold a current medicines administration competency certificate (Level 3 or above, or equivalent). Renewal dates are within the required cycle | ||
| D2 | A list of which staff are authorised to administer medicines is documented and accessible. No unauthorised staff have administered medicines | ||
| D3 | A medicines administration competency observation has been completed for at least one new or agency staff member this month | ||
| D4 | Staff who administer specialist medicines (insulin, warfarin, PEG feeds, subcutaneous medications) hold the relevant additional competency | ||
| D5 | Any medicines-related incident or near miss has been recorded, investigated, and used as a learning opportunity. Staff involved have been briefed |
Score Summary
| Section | Total Items | Pass | Fail | % |
|---|---|---|---|---|
| A: Storage | 10 | |||
| B: MAR Charts | 10 | |||
| C: Controlled Drugs | 8 | |||
| D: Competency | 5 | |||
| Total | 33 |
Auditor Sign-Off
| Ref | Action Required | Responsible Person | Target Date | Completion Evidence | Date Completed |
|---|---|---|---|---|---|