Medicines in health and adult social care: learning from risks and good practice for better outcomes

care quality commission

The independent regulator of health and social care in England

Medicines in health and adult social care

Learning from risks and good practice for better outcomes

Medicines in health and adult social care

We have published a report sharing the learning from risks and good practice in medicines optimisation, which we have found on our inspections. 

Many of the services that CQC regulates have a role in managing medicines. Through inspection, we have seen that medicines can present a clear risk to people when not used properly.

When CQC inspects health and care services we assess how well they meed people's needs. As part of this, we look at how people's medicines are optimised. Medicines optimisation is the safe and effective use of medicines to enable the best possible outcomes for people. It also looks at the value that medicines deliver, making sure that they are both clinically and cost effective, and that people get the right choice of medicines, at the right time, with clinicians engaging them in the process.

We do this through a dedicated team of pharmacy professionals who work across the country providing specialist advice on the use of medicines in all settings. This includes being on site at inspections, inputting into decisions on enforcement and supporting CQC's policy teams. 

From our analysis, we have categorised the most common areas of risk with medicines across regulated health and adult social care services. You can read these in more detail, along with our suggested actions for all health and social care providers, in the main report. 


The report also examines what a number of these themes mean in the context of mental health service provision. Some of the main areas of risk that we found in our analysis related to rapid tranquillisation and the prescribing and monitoring of high dose antipsychotics. 

We explore some of these themes in more detail below, along with examples of good practice, but you can jump straight to the mental health section of the report by clicking from the contents section of the main report. 


Prescribing, monitoring and reviewing high-risk medicines

Rapid tranquillisation

Appropriate and safe rapid tranquillisation practice is an important theme for providers of mental health services. It is essential to monitor patients’ physical health, as there is a risk of adverse effects. Rapid tranquillisation was the largest single issue to emerge from the analysis of NHS trust inspection reports, but we also found it to be an issue for independent mental health services.

High-dose antipsychotic therapy

We found that people who were prescribed antipsychotic medicines were not always receiving the necessary health checks. A specific concern related to patients who were prescribed doses above the British National Formulary (BNF) recommended limit, often referred to as high-dose antipsychotic therapy (HDAT).

In some cases, patients were not monitored because there were no systems to support the process. In other cases, staff did not follow the trust’s policy, sometimes because they were not trained, or because it was not clear who was responsible for the different aspects of monitoring people on HDAT. This was not just in NHS trusts, but extended to organisations in the wider healthcare system.



Transfer of care

A number of the notifications in our analysis occurred at the point when people were discharged or transferred to the care of another service. 

Problems arose when medicines records were not transferred, resulting in missed doses. Complex titration plans were sometimes unclear or the new care provider could not understand them. In other cases, GPs made prescribing errors as a direct result of incorrect discharge summaries.

Those who reported incidents articulated the need for better communication between wards and teams. The crucial role of medicines reconciliation was clear in notifications involving transfers of care; these highlighted where this was not being carried out robustly.

MH transfer of care


Clinical input from pharmacy professionals

Inspection reports highlighted the valuable input of pharmacy staff and how they help to ensure safe practices around medicines. However, limited capacity of small teams and insufficient pharmacy resource was a consistent theme in inspection reports analysed for NHS mental health trusts. This meant that pharmacists were not participating in multidisciplinary team meetings and that in some trusts, there was no pharmacy input or support into high-risk clinical areas. In some cases, community-based mental health teams had no medicines management support allocated to them.

Some providers chose to increase the capacity of their pharmacy teams with additional pharmacists, pharmacy technicians and non-medical prescribers. We saw through our inspections that even small changes can help make improvement. 

The role of medication safety officer (MSO) can also play a role in working towards safer use of medicines in a mental health setting. One of the key responsibilities for MSOs is ownership of reporting medicines incidents, which involves improving reporting rates and promoting learning among staff. By giving this role higher prominence within a trust, boards can be aware of issues and track progress on medicines safety. 

Actions for mental health providers

Based on the risks identified with medicines use in mental health care settings, we encourage providers to take the following action to ensure that medicines are managed safely:

  1. Procedures for rapid tranquillisation by injection need to be strengthened. Importantly, staff need to be trained to recognise the need for this, to deliver rapid tranquilisation safely and to monitor people’s physical health appropriately.
  2. There is a need to focus on improving how high doses of antipsychotic medicines are prescribed and monitored.
  3. Audit processes and governance structures should enable staff to challenge prescribing and administration that is not in line with national guidance, or a person’s consent to treatment.
  4. Good physical health monitoring, including the side-effects and effectiveness of the prescribed medicines, must be considered central to everyday practice.
  5. The role of medication safety officer is crucial to the oversight and responsibility for safety in mental health settings. This role should have higher recognition at board level. By providing updates on areas of concern from a medicines safety officer, a trust’s board can be aware of issues and track progress on medicines safety.

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