Care home audit checklist for medication: the monthly medication audit for managers

A monthly medication audit is the registered manager's own check that medicines in the home are being managed as the policy says: MAR charts complete, stock reconciling, controlled drugs correct, PRN protocols in place and followed, storage safe, consent recorded, staff competent and errors reviewed. It is one of the care home audits inspectors ask for first, and its value lies in the actions it produces and the trend it shows over months.

The short answer

Audit medicines every month using a fixed care home audit checklist so that the same things are checked the same way each time. Audit every resident for controlled drugs, high-risk medicines and anyone with a recent error, and a rotating sample of the rest. Score each area against stated criteria, record the evidence, and turn every shortfall into an action with an owner and a date. Check last month's actions first. Involve the supplying pharmacist at least annually. Keep the audits in the governance file and be ready to show an inspector the last six months, the trend and what you changed. An electronic MAR takes most of the counting out of the audit and leaves the manager free to look at the things a report cannot see: the storage, a round, a conversation with a carer.

Why monthly, and who does it

Medicines are the area of a care home most likely to produce a Regulation 12 breach, and the failures accumulate quietly: a gap on a MAR here, a PRN given a bit too often there, a fridge running warm for a fortnight, a controlled drugs balance that has been out by one since March. A monthly audit catches these before they compound. Quarterly is too long; problems have become patterns by then.

The auditor should be the registered manager, deputy or a nurse, and ideally not the person who does most of the rounds, because the point is an independent look. In a small home that may not be possible, in which case swap with a manager from a sister home occasionally or ask the pharmacist to co-audit. The manager signs off every audit regardless of who completed it, because Regulation 17 places good governance on the registered person.

Timing matters. Audit at the same point each month, ideally just after the monthly delivery so stock is at its clearest, and set aside the time; a proper audit of a 30-bed home takes two to three hours on paper and about an hour with electronic records.

At a glance: what the monthly audit covers

Start with last month's actions

Before you check anything new, open the previous audit and go through the actions. Was each one done, by whom, and did it work? An action that is still open after two months is a governance finding in itself, and an inspector reading six audits will look for exactly this: the same item appearing again and again with no resolution.

Record the status of each action at the top of the new audit: closed with evidence, open with a revised date and reason, or escalated. If an action keeps slipping, ask why. Usually the answer is that the action was too big, not owned by anyone in particular, or depended on someone outside the home such as the pharmacy or the GP practice, in which case the action needs to become a documented request with a chase date.

This step turns the audit from a monthly snapshot into a rolling improvement record. It also makes the audit shorter over time, because problems actually get fixed.

MAR charts

For each resident in the sample, check the current MAR chart and the previous month's. Look for every dose signed or coded with an approved code; no blank boxes. Handwritten entries checked and countersigned by a second person, with the source of the instruction recorded. A photograph, date of birth, allergies and GP on every chart. Directions that match the label and the prescription. Start and stop dates for courses. Times of administration that match the prescriber's intention, not the home's convenience. Variable doses, such as warfarin, with the actual dose given recorded.

Count the gaps and the codes. A cluster of missed doses on one shift or one round tells you something about staffing or interruptions. A lot of refused codes for one resident tells you about consent or approach. Record the numbers so next month can be compared.

With an eMAR most of this is a report: gaps, late doses and unsigned entries by round and by staff member. Use the report as the evidence and spend the time on the residents it flags, and audit the codes against your written code list.

Stock reconciliation

For each resident in the sample, and for every high-risk medicine across the home, count the stock and reconcile it against the quantity received, the doses recorded as given and any returns or disposals. The count should match. Where it does not, record the discrepancy and investigate: was a dose given and not signed, signed and not given, dropped and not recorded, or returned without a record?

High-risk medicines to reconcile fully every month are controlled drugs, insulin, anticoagulants, opioids not in schedule 2, antipsychotics and anything the pharmacist has flagged. Liquids reconcile approximately, so record the date opened and expected use and look for gross discrepancies rather than millilitres.

Look at the excess too. Overstock indicates doses not given, or repeat prescriptions ordered without checking, and it costs the NHS money that the ICB medicines team will notice. Record the quantity returned to the pharmacy each month and ask why it was ordered.

Controlled drugs

Controlled drugs are audited in full every month, and the audit checks the process as well as the count. Every controlled drug in the cabinet has a register entry with a running balance, and the balance matches the count. Every administration has two signatures, the giver and a witness. Every receipt and every return or disposal is recorded with a witness. The running balance has been checked and signed at each handover of the keys, or at the frequency your policy sets, which should be at least weekly and is daily in most nursing homes.

Check the cabinet itself: fixed to a solid wall, the right specification, keys held by the person in charge and not left in the door or in a drawer. Check that nothing is in the cabinet that should not be, and nothing that should be is elsewhere. Check that controlled drugs for residents who have died or left have been returned and recorded.

Any discrepancy is an incident: record it, investigate it the same day and, if it cannot be resolved, report it to the CQC controlled drugs accountable officer for your area and consider the police. See controlled drugs in care homes for the full process.

PRN medicines

For each resident in the sample, and for every resident who received a PRN more than a handful of times this month, check that each PRN has a written protocol that says what it is for, the dose and interval, the maximum in 24 hours, the signs that mean it is needed, what to try first and the review date. Then check the MAR: each PRN dose has a reason recorded, a time, and an outcome recorded within a reasonable period. The interval between doses respects the protocol and the daily maximum was not exceeded.

Look at frequency. A PRN given daily for a month is a regular medicine and needs the GP to review it. A PRN never given in six months may not be needed. A PRN for agitation given on the same shift every week says something about the shift, not the resident. Record what you find and send the GP a list of PRNs to review.

Check the controlled drug PRNs and the psychotropic PRNs particularly closely, because these are the ones an inspector will scrutinise. See PRN medication protocols for the standard to audit against.

Storage and temperatures

Walk the medicines room and every trolley and cupboard. Medicines room temperature recorded daily and below 25 degrees; fridge temperature recorded daily with minimum, maximum and current readings, between 2 and 8 degrees, and the thermometer reset. Any out-of-range reading has a recorded action: what was done and whether the pharmacist was consulted about the medicines inside.

Everything locked when not in use, keys held by the person responsible, trolley secured to the wall when not on the round. No medicines for residents who have left or died. No out-of-date stock, with dates checked on liquids and eye drops that have short lives once opened. Residents' own medicines held separately and labelled. Thickeners, dressings, nutritional supplements and oxygen stored and recorded as your policy requires.

Check the clinical waste and the returns process: medicines for disposal recorded, bagged and collected, and the collection receipt kept. Check that nothing is being disposed of in the general waste or down the sink.

Consent, capacity and covert administration

For every resident receiving any medicine covertly, check there is a capacity assessment for that decision, a best interests decision that involved the prescriber and the pharmacist, a care plan entry that says which medicines, how they are disguised and in what, a review date, and evidence that the pharmacist confirmed the medicine can be crushed or mixed. Check the MAR shows covert administration clearly.

For the sample of other residents, check that consent to medication is recorded in the care plan, that residents who self-administer have a risk assessment with a review date, and that any medicine given under a Mental Health Act section or a DoLS authorisation is recorded with the authority for it.

Refusals are a consent matter too. A resident who refuses regularly needs a plan: the reason explored, the GP told, alternatives considered. Check the plan exists for anyone with frequent refusal codes on the MAR. Your care records should hold the capacity assessment and the best interests decision beside the medication plan.

Homely remedies and residents' own medicines

Check the homely remedies list is signed by the GP practice, dated and within its review period. Count the stock and reconcile it against the stock record and the MAR entries across all residents. Check expiry dates. Pull the month's homely remedy doses and confirm each has a reason, that no daily maximum was exceeded, that no resident had a homely remedy for more than 48 hours without a GP contact recorded, and that nobody received a homely remedy while prescribed the same ingredient.

Check residents' own over-the-counter and herbal products: recorded in the care plan, confirmed with the GP or pharmacist, and covered by a self-medication risk assessment where the resident keeps them. Walk two or three bedrooms and look at the bedside tables.

Note anyone who has had a homely remedy more than twice this month for a GP conversation about a proper PRN.

Staff competency and training

List every member of staff who administered medicines this month, including agency and bank staff, and check that each has a current competency assessment, dated within the last twelve months, and medication training within your policy period. Check that anyone involved in an error this month has had a competency review since. Check that new starters have not administered before being signed off.

Then observe a round, or part of one, at least every quarter, and record what you saw: the six rights checked, the MAR signed at the time, hand hygiene, the trolley secured, PRN decisions made properly, residents given time and the medicine actually taken before signing. An observed round finds things no record can, and inspectors do exactly this.

Record competency and training in the staff file where it can be produced for the people on shift on any date. HR and training records linked to each staff member make this a report rather than a search.

Medication errors and learning

List every error and near miss recorded this month. For each, check that the resident was made safe and clinical advice was sought, that the incident record is complete, that the manager reviewed it for root cause, that actions were recorded with owners and dates, that the staff member had a competency check and supervision, that the resident and family were told, and that the CQC notification and safeguarding decisions were made and recorded.

Then look at the pattern: type of error, shift, round, staff member, resident, medicine. Write two or three sentences on what the pattern shows and what is changing. Compare with the previous months. A month with no recorded errors should prompt the question of whether errors are being reported, not a sense of relief.

Check that error learning reaches the staff. Look for the minutes of the staff meeting or the handover note where errors were discussed. See medication errors in care homes for the standard each error record should meet.

Ordering, receipt and reconciliation with the pharmacy

Check the monthly order was reconciled against the delivery, item by item, and any discrepancies were raised with the pharmacy and recorded. Check the MAR charts from the pharmacy match the prescriptions. Check that interim prescriptions and hospital discharge medicines were reconciled against the existing MAR within 24 hours and any changes confirmed with the GP. Check that medicines stopped by the GP were removed from the trolley and the MAR the same day.

Look at the relationship with the pharmacy more broadly. How many dispensing errors this year? How quickly are queries answered? Is there a service level agreement? A pharmacy that repeatedly delivers late or wrong is a risk the home needs to manage and document.

Check that the ICB medicines optimisation team or the pharmacist has reviewed residents' medicines within the last year and that the recommendations were actioned.

Sampling versus full audit

Some areas are audited in full every month because the risk is too high to sample: controlled drugs, covert administration, high-risk medicines, homely remedies stock, storage and temperatures, staff competency, and errors. For MAR charts, stock and PRN, sample a third of residents each month and rotate so that everyone is covered every quarter. Add to the sample anyone with a recent error, a recent admission or discharge, a medicines review outstanding, or a complaint.

Record which residents were sampled and why. An inspector will want to see that the coverage is systematic rather than the same easy residents every month. A simple grid with residents down the side and months across the top shows the rotation at a glance.

Where a sample finds a problem, widen it. Three unsigned doses in a sample of ten residents means checking all thirty that month.

How to score and record it

Use a fixed template so the audit reads the same every month. For each item, state the criterion, the evidence checked, the finding, and a rating: compliant, partially compliant or not compliant. Then, for every partial or non-compliant item, an action with an owner and a date. A short summary at the top gives the overall picture and the three most important actions.

A percentage score is useful for tracking trend over months and for reporting to owners or a board, but it should never be the only output. Inspectors are far more interested in the actions and whether they were done than in whether the home scored 87 or 91 percent. Do not let the score drift upward because the criteria have softened; the criteria stay the same and the score reflects reality.

Sign and date the audit, share the actions with the people who own them, and file it in the governance folder with the previous months. An audit template inside a CQC compliance system keeps the criteria fixed, holds the evidence and carries the actions forward automatically.

The monthly medication audit checklist

• Previous audit actions reviewed and status recorded.
• MAR charts sampled: no gaps, approved codes, handwritten entries countersigned, photos and allergies present, directions match labels.
• Stock reconciled for the sample and all high-risk medicines; discrepancies investigated.
• Controlled drugs: register balances match counts, two signatures throughout, cabinet and keys correct, handover checks done.
• PRN: protocol for every PRN, reason and outcome for every dose, intervals and maximums respected, frequent users listed for GP review.
• Storage: room and fridge temperatures recorded daily and in range, out-of-range actioned, everything locked, no expired or discontinued stock.
• Consent: covert administration fully documented, self-administration risk assessed, refusals planned for.
• Homely remedies: list signed and current, stock reconciled, doses recorded with reason, 48-hour rule followed.
• Staff: competency and training current for everyone who administered this month, observed round recorded this quarter.
• Errors: every error and near miss reviewed, actions recorded, notification and safeguarding decisions recorded, pattern analysed.
• Pharmacy: delivery reconciled, discharges reconciled, stopped medicines removed, annual medicines review done.
• Summary written, actions owned and dated, audit signed and filed.

Running the audit step by step

1. Book the time, ideally the day after the monthly delivery, and tell the senior on shift so the trolley and keys are available.
2. Review last month's actions and record their status.
3. Choose this month's sample and record it.
4. Run the eMAR reports if you have them: gaps, late doses, PRN frequency, stock discrepancies, temperature exceptions.
5. Walk the medicines room, trolleys, fridge and cabinet with the checklist.
6. Audit controlled drugs in full with a witness.
7. Audit the sample residents' MAR charts, stock, PRN protocols and consent records.
8. Check homely remedies and residents' own medicines.
9. Check staff competency and training for everyone who administered this month.
10. Review the month's errors and near misses and write the pattern analysis.
11. Score, write the summary, set the actions with owners and dates, sign and file.
12. Brief the team at the next handover or staff meeting on the findings and the actions.

Learning disability and mental health services

In these services the audit puts more weight on psychotropic medicines, PRN for behaviour, consent and covert administration. Check every psychotropic has a documented indication and a review date in line with STOMP, and that PRN for agitation or distress has a protocol that starts with non-drug approaches and records what was tried first. Check that any medicine given under the Mental Health Act has the right paperwork and that any restriction connected to medication is in the care plan and, where relevant, the DoLS or LPS authorisation.

Look at the link between medication and other records: does the behaviour monitoring show a change after a dose adjustment, is the physical health monitoring for antipsychotics being done, is weight being recorded. The audit is the place to ask whether the medicines are still doing what they were meant to do.

Residents who self-administer are more common here, so the self-medication risk assessments and the arrangements for storage in bedrooms need checking every month.

Using the audit at inspection

Inspectors ask for the medication audits at almost every inspection and read the last three to six months. They look for whether the audit is honest, whether the same problems recur, whether actions are closed, and whether the audit connects to the errors and the staff meeting minutes. An audit that finds nothing every month reads as a tick-box exercise; an audit that finds four things, fixes three and carries one forward with a reason reads as governance.

Have the audits ready in date order, with the action logs, and be able to talk about one improvement that came from them: fewer missed doses after rounds were protected, PRN use down after protocols were rewritten, fridge exceptions eliminated after a new thermometer. That story, backed by the numbers, is worth more than the score.

If you use an electronic system, be ready to show the reports the audit relies on so the inspector can see the evidence is real rather than transcribed. Kiwi's eMAR produces the gaps, PRN and stock reports the audit needs, and the incident review carries the notifiable flag, so the audit evidence is on screen rather than reconstructed. Book a demo if you want to see how that fits your audit.

Common mistakes

• Auditing the same easy residents every month rather than a rotating sample.
• Not checking last month's actions, so the audit finds the same things each time.
• Counting stock without reconciling it against the MAR and receipts.
• Controlled drugs counted but the witness signatures and handover checks not examined.
• PRN protocols present but PRN frequency never analysed.
• Fridge temperatures recorded but out-of-range readings never actioned.
• Competency checked against certificates rather than observed practice.
• A score reported to the board with no actions behind it.

What good looks like on inspection day

The manager can produce the last six audits within a minute, each signed, each with actions and their status. The inspector can see a problem found in March, fixed in April and not recurring since. The controlled drugs register balances on the day. The fridge log is complete and the one out-of-range day has a note saying what was done. Every PRN sampled has a protocol and every dose has a reason and an outcome. The staff member asked about competency can say when they were last observed and by whom.

The inspector can ask any question about medicines and the manager answers from the audit rather than from memory. That is what a monthly audit, done properly, delivers.

Final conclusion

A medication audit is not a form to complete; it is the manager's monthly check that medicines are as safe as the policy claims. Use a fixed checklist, audit the high-risk areas in full and the rest by rotating sample, start with last month's actions, record the evidence, score honestly, and turn every shortfall into a dated action that somebody owns. Six months of audits done that way is the clearest evidence a home can offer that its medicines are managed safely, and it is evidence you built for yourself, not for the inspector.

Frequently asked

How often should a care home audit its medication?

A full medication audit monthly, a controlled drugs count at least weekly and at every handover of the keys, fridge and room temperatures daily, and a MAR check for gaps at the end of every round. Ask the supplying pharmacist or the ICB medicines optimisation team to audit alongside you at least once a year.

Who should complete the medication audit?

The registered manager, deputy or a nurse, and ideally not the person who does most of the administration. The point is an independent look. Rotate the auditor occasionally so the same blind spots do not persist, and have the manager sign off every audit even if someone else completed it.

What should a care home audit checklist for medication include?

MAR charts, stock reconciliation, controlled drugs, PRN protocols and use, storage and temperatures, consent and covert medication, homely remedies, staff competency and training, medication errors and learning, and the actions from the previous audit. Score each area, record the evidence, and produce dated actions with owners.

Should I audit every resident or a sample?

Audit every resident for controlled drugs, high-risk medicines and anyone with a recent error. For the rest, sample a third of residents each month so that everyone is covered quarterly, and rotate the sample. Record which residents were sampled so the coverage is visible.

What is a good scoring method for a medication audit?

Score each area as compliant, partially compliant or not compliant against stated criteria, with the evidence noted. Then turn every partial or non-compliant item into a dated action with an owner. A percentage is useful for tracking trends over months, but the actions are what inspectors want to see.

Will an inspector ask to see my medication audits?

Yes, almost always. They will ask for the last three to six months, check whether the same problems appear repeatedly, and ask what changed as a result. An audit that finds nothing every month is less convincing than one that finds problems and shows them being fixed.

Can medication audit software replace the manual audit?

It can remove most of the counting and cross-checking, because an electronic MAR shows gaps, late doses, PRN frequency and stock discrepancies automatically. The manager still needs to look at the storage, watch a round, check competencies and review errors, and still needs to write the actions. Use the software reports as the evidence base rather than as the audit itself.

Sources

• NICE SC1 Managing medicines in care homes
• CQC: Medicines in health and adult social care guidance
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 Safe care and treatment and Regulation 17 Good governance
• Misuse of Drugs (Safe Custody) Regulations 1973
• Controlled Drugs (Supervision of Management and Use) Regulations 2013
• Royal Pharmaceutical Society: The Handling of Medicines in Social Care
• Specialist Pharmacy Service: care home medicines guidance