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

Today, 6 June 2019, we have published a report sharing the learning from risks and good practice in medicines, 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 for adult social care. Our findings are based on analysis of inspection reports from a range of settings across adult social care, enforcement notices and statutory notifications that CQC received. 

Over 20,000 adult social care services are registered with CQC, including care homes (with or without nursing care), home care service and shared lives schemes. Each type of service supports people with their medicines differently, depending on their needs. Some key themes were evident in our analysis, including medicines administration and record keeping. 

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

Resident and carer in care home

Medicines administration

A number of the areas of risk that we found related to issues around administration of medicines. 

Administering an incorrect dose of medication was the most commonly-reported error in statutory notifications from adult social care services. This happened for a variety of reasons ranging from record keeping, to ongoing pressures on staff. 

As will all service types that CQC regulates, we found problems with administration of 'when required' medicines, such as pain relief, or asthma reliever inhalers. Staff in adult social care services did not always have enough information to ensure that they were able to support people with these medicines.

Our analysis also showed us that providers need to consider their requirements when administering medicines covertly. We found that providers did not always comply with the Mental Capacity Act, or act on guidance on how to alter medicines safely. We did however find some excellent examples of steps taken to reduce repeated refusals of medicines, which prevented the need for medicines to be administered covertly. 



The role of pharmacy professionals

In our actions for adult social care providers, we suggest that you should consider having an attached or named pharmacist to support staff with medicines management issues. 

The support of a pharmacy professional would help with many of the key themes and issues that we found in our analysis. This is especially true when people who use services move between adult social care and secondary care services. 

We identified that some medicines errors in care homes happened because of a disparity in the medicines that were supplied and the information in the discharge summary. In some cases, care home staff also misinterpreted instructions on discharge summaries.



Staff training and competence

NICE guidance states that staff should have an annual review of their skills and competency. We found some providers were not carrying out competency assessments or regular competency checks. Some staff reported to us that they had not received any formal medicines training. 

We also expect to see clarity over who is responsible for training staff about medicines and that this training is kept up-to-date.

Actions for adult social care providers

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

  1. Adopting best practice guidance will improve safety and outcomes for people, specifically NICE guidance for managing medicines in care homes (SC1) and in the community (NG67). As well as care providers, this is also relevant for commissioners, GPs, pharmacists and healthcare professionals.
  2. Providers of adult social care should consider having an attached or named pharmacist to support staff with medicines management issues. More specifically, closer working can help to implement guidance and training on administering medicines covertly, ‘when required’ (PRN) medicines, and those required as part of end of life care.
  3. Training staff and assessing their competency in handling and administering medicines should be an ongoing priority. It should be clear who is responsible for training staff about medicines and that this training is kept up-to-date.
  4. It should be made clear who has ongoing clinical responsibility and oversight of medicines. Expectations around responsibility should be clear in the contracts that local authorities and CCG commissioners issue to providers.
  5. The new role of nursing associate may help to ease pressure on nursing staff in care homes, but providers must make sure that they are deployed safely and effectively, with the appropriate competencies and supervision when their work involves medicines.
  6. Adopting NHS England initiatives such as Enhanced Health in Care Homes and Medicines Optimisation in Care Homes can help drive improvement by involving pharmacists and providing joined-up primary, community and secondary care to residents of care and nursing homes.

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