GO Online: Inspection toolkit

Medicines optimisation

Medicines remains one of the more common areas of unsafe practice amongst services rated inadequate or requiring improvement. Where good and outstanding rated practice exists, effective processes, training and support are key.

The following film provides a summary of this area of inspection. It can help you and your teams learn about what will be inspected and what is important to demonstrate to deliver good or outstanding care.

Medicines optimisation

• We can evidence how we support people to manage their medicines.
• We ensure our medicines related policies and procedures are aligned with the latest good or best practice.
• We ensure our medication policies are co-produced with our teams, GP’s, and our pharmacist along with any other relevant healthcare professionals.
• We ensure our homely remedies policy is co-produced with relevant professionals and advice is sought if there is a new medication someone using the service would like to commence.
• We activity support people to manage their own medicines and retain independence, including working closely with other agencies and advocates where needed.
• We involve the people we support (and/or their families) in regular medicine reviews and risk assessments. We consider any associated cultural or dietary requirements when planning these.
• We keep detailed and current information regarding people’s medicines and how people prefer these to be administered recorded in their care plans.
• We ensure our staff team are clear about their roles and responsibilities related to supporting people to manage medicines.
• We ensure staff have access to detailed information about each type of medicine a person has been prescribed, as well as any possible side effects.
• We ensure our staff effectively communicate with the people they support when administrating medication, including clearly advising about the possible side effects and explaining what each medicine is for.
• Where relevant to our service, the people we support who’ve been assessed as lacking capacity are only administered medicine covertly if a management plan is agreed after a best interest meeting. This is in accordance with NICE Quality Standards.
• We ensure our staff understand the risk of using non-prescribed or unlicensed medicines.
• We ensure our staff understand the opportunities and risks associated with natural remedies and over the counter medicines.
• We ensure that medication and administration records (MAR) are fully completed and contain the required entry information and signatures.
• We ensure medicines are well managed and in line with current NICE and Royal Pharmaceutical Society (RPS) guidelines. This includes the controlled medicines.
• We ensure medicines are stored in a secure area at the correct temperature, as well as ensuring the safe disposal of medicines.
• We record evidence of medications storage including temperatures in line with heatwave or cold weather planning.
• We ensure our staff receive medication training and what is covered is clearly documented so we know what medication tasks different staff can perform.
• We ensure our staff understand the arrangements in place for ordering and disposing of medicines.
• We proactively involve healthcare professionals whenever we believe that medication changes may be required. This may involve a multidisciplinary team on occasions.
• We assess medication administration competency before new staff work out of sight of more experienced colleagues. We ensure refresher training and assessment is undertaken periodically.
• We undertake regular medicine management spot checks and audits to monitor safe practices and stock. Where appropriate, we involve a pharmacist in our annual audits for medication.
• We effectively manage a person’s medication when they are moving between services.
• We use technology to help strengthen record keeping, providing opportunities to instantly update and reduce risks from bad handwriting etc.
• We fully investigate any medicine errors and ensure our service learns from such mistakes to mitigate them reoccurring.
• We create a culture of learning from medication errors and undertake a review and analysis for incidents or near misses.

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