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What are Care Quality Commission inspectors likely to focus on during inspections of health and social care providers? We look at some key focus areas, including MAR charts, PRN protocols, covert medication documentation, stock management protocols and paperwork, and staff training.
Medical Administration Record (MAR) charts
MAR charts are a person’s legal medication administration record and form part of their permanent medical chart. They are also crucial in ensuring accurate and safe medication administration. Inspectors will, therefore, review MAR charts, so ensuring they are completed and signed every time a medicine is given is critical. Some particular issues to note include:
Time-sensitive medications: Any medication prescribed for a specific time should be given at that time to ensure the best results. As part of the duty of care, a robust process should be in place and evidenced to ensure compliance.
Variable dose medicines: The dose should be documented on the MAR.
Medications not given: All prescribed medications should be administered unless there is a specific reason not to, which should be documented using the correct code. It’s unacceptable for people to miss doses without cause; this would be considered a safeguarding issue. Repeated refusal should be reported to the GP.
Topical treatments: It is just as critical that prescribed topical treatments are signed as administered as it is for oral medications—yet this is a common omission. A body map should also be in place that details where, when, and how the product should be applied.
Transcribing medications onto a MAR: Ideally and when practical, two staff members should do this, confirming the accuracy of the details on the MAR.
Opening date: This should be recorded on the MAR for all topical and liquid medicines to prevent them from being used past their expiry.
PRN protocols
Providers must ensure protocols are in place for all PRN prescription medications, including topical treatments. The protocol should provide detailed information about the medication and why it should be administered, and it should also be signed and dated. Protocols should be updated with any changes to medication or doses.
It is important to note that when PRN medications are administered, the administrator should detail why they were administered and review their effects on the service user.
Covert medications
Any service users receiving covert medication under the Mental Capacity Act 2005 should have an appropriate mental capacity assessment and best interest decision in place. The service user’s care plan should reflect this and detail how the medication should be administered. This should be reviewed regularly.
Stock management
All stock should be appropriately signed into the service with (ideally) two staff signatures, although this is not always practical. Staff should ensure any unused stock is carried forward to provide an accurate stock balance. Any stock disposal should also be documented to ensure an evidence trail can be provided when asked for.
Medication should be labelled correctly and matched with the MAR chart. When signing in medications, any labelling issues should be identified, and the medicine should be returned to the supplying pharmacy for re-labelling.
Temperature checks for medication fridges should be recorded on dedicated temperature log forms, readily available and retained for a specified period. This ensures medications are stored at the correct temperatures, maintaining their efficacy and safety. If the temperature goes significantly out of range, you should be able to demonstrate the corrective action taken.
Staff training
All staff responsible for administering medications should complete a training course and receive a competency assessment at least annually from a trained and competent person – and more frequently if issues are identified. All training and assessments should be recorded in the staff record and available to inspectors for review.
For more information on Current focus areas for social care providers in CQC inspections talk to W&P Assessment and Training Centre