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GO Online: Inspection toolkit

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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.

Introducing Medicines optimisation

Duration 01 min 57 sec

Whatever role your service has in regard to people’s medicines, it’s important that your processes and procedures are robust.

You’ll need to be clear about your staff roles and responsibilities around medicines … and ensure that people receive them as prescribed.

NICE guidelines will need to be followed and the CQC inspectors will want to assure themselves that your service is safely managing the ordering, transporting, storage, and disposal of medicines.

Your staff will be expected to be effectively trained and assessed as competent in how they administer and record medicines.

Regularly use opportunities such as one-to-ones to discuss medication issues and check understanding with staff.

Your staff will also need to be confident to discuss medicines with the people you support, and ensure this information and advice is clearly communicated.

Involve the people you support in how their medicines are managed. Try to encourage independence. Correct procedures will need to be followed, including when supporting people with limited capacity.

Your medication management may also need to involve external healthcare professionals.

The CQC inspectors will review data from your service prior to interviewing people, staff, and managers. Be prepared for the CQC inspector to accompany your staff and observe them administrating medication.

The inspectors may also ask to see a range of documents related to your medication management including:

  • medicine administration records
  • medicine review
  • medicine training
  • and medicine protocols.

Take a look at the recommendations, examples, and resources in our GO Online resource to help you to safely manage medicines.

Watch the film here:

Practical examples

The examples below provide insight into how other Good or Outstanding rated services are succeeding in this area of inspection. Use the filter to choose different types of examples or select based on related prompt.

If you have an example you would like to share, please e-mail employer.engagement@skillsforcare.org.uk.

Filter by resource type


12 example(s) found

Working closely with the psychiatrist to manage medicines

Staff had achieved outstanding outcomes for autistic people by supporting medical professionals to reduce or stop a reliance on medicines and explore alternative ways to help people manage their needs.

The provider identified a previously unrecognised negative impact on a person's wellbeing due to the side effect of an anti-psychotic medicine. Staff worked closely with the psychiatrist to develop a support plan and provide additional staffing to allow the person to reduce the use of this medicine.

This improved the person's wellbeing in other areas of their life. Only one antipsychotic medicine remained for the person, so the staff team then worked with the psychiatrist to remove this, resulting in the autistic person being free of all antipsychotic medicines and their case closed to psychiatry services after decades of treatment. The person was able to live successfully in their community with a reduced support package. 

Read more about the service .

Care provider: Avenues South East

  • Case study

Date published: November 2022


Using NICE guidance to support collaborative working with specialists

This provider implemented new medicines policies using . To ensure their medicines procedures were stringent, they worked with pharmacists to incorporate specialised knowledge. Throughout, their service they have found NICE’s shared remit for producing guidance across health and social care enabled strong collaboration with other professionals including social workers, commissioners, GPs, nurses, dentists, and more.

See also: NICE social care quick guides

Care provider: Anonymous

  • Case study

Date published: January 2022


Using NICE guidance to safely manage medicines in homecare

Services use to develop a medicines policy for their home care network. This ensured best, safe and robust practice for their home care network, leading to positive outcomes for their clients. The NICE guidance are easy to follow and a great resource for medicines policy development.

See also: NICE social care quick guides

Care provider: Anonymous

  • Case study

Date published: November 2021


Working closely with the local system Medicine Optimisation in Care Homes team

The service had worked with the local Medicine Optimisation in Care Homes team (MOCH) to improve medicine practise in the service.

The MOCH team’s feedback to the CQC stated: “Davers Court is one of the most engaged care homes that we’ve visited. The management and staff have always been keen to learn and have certainly encouraged the residents (where capacity is present) to participate in conversations about their medications. I’d go so far as to say that the medication rounds observed, the processes and procedures followed, and the conversations had with residents around the taking of medications were exemplary.”

Read more about this service .

Care provider: Davers Court - Care UK Community Partnerships Ltd

  • Case study

Date published: March 2020


Managing medication effectively to improve behaviour

Staff supported one person who had very challenging behaviour and wanted to stay in bed all day. Staff displayed great passion and commitment to improve this person's life. They explained how they advocated for the person challenging other healthcare professionals to change the person’s medication and level of one-to-one support they required. As a result, the person’s behaviour has now totally changed; they’ve been able to go on holiday and the service is now looking at moving them to a supported living service.

Read more about this service .

Care provider: Landermeads Care Home

  • Case study

Date published: March 2020


Medication champion

There was a medication champion amongst the staff team. This staff member was responsible for overseeing the medicine processes and procedures and researching the latest and best practice. This included ensuring training was up-to-date, ordering and checking in medicines, conducting monthly spot checks and audits, reviewing new projects, and sourcing guidance and research in relation to medicines in care home settings, such as STOMP.

Read more about this service .

Care provider: SENSE - 89 Hastings Avenue

  • Case study

Date published: April 2019


Stomping out over medication

The service had signed up to the STOMP pledge (Stopping the Over Medication of People with a learning disability, autism or both), an initiative set up by the NHS. STOMP is a national initiative.

The registered manager worked with the lead NHS STOMP nurse. The training was then provided to all staff by a local training company, and provided details of what medicines were used for, and support with the confidence to challenge whether the medicines were needed.

The service developed a STOMP champion role so that staff were informed and advised of best practice. An audit of psychotropic (any medication capable of affecting the mind, emotions, and behaviour) drug use was undertaken to inform the STOMP pledge and staff training.

Read more about the service .

Care provider: Community Support Service (D.D.H. Services Ltd)

  • Case study

Date published: March 2019


Designing your processes around NICE guidelines

The lead nurse devised a practical assessment tool in-line with NICE guidelines to ensure all staff administering medicines were assessed every three months against all aspects. This included storage and disposal, as well as administration.

Care provider: Anonymous

  • Case study

Date published: April 2018


Self-medication plans

Each person wishing to manage their medicines had a self-medication plan containing information as to: “what’s important to me regarding medication?”, “what do I need to do around medication?” and “how can staff support me with medication?”

Care provider: Anonymous

  • Case study

Date published: April 2018


Best-interest decisions

One person was declining their medicines and the registered manager, with input from the GP, had assessed the person’s capacity to see if they understood the risks of not taking their medicines. The assessment detailed the most suitable environment for the conversation and the best time of day had been considered. The person was assessed as not having the capacity. A best-interest decision meeting was held with a multidisciplinary team, including the person’s family and GP, where a decision was reached and recorded.

Care provider: Anonymous

  • Case study

Date published: April 2018


Using supervision to investigate medication incidents

After any medication-related incident, the service responds quickly to arrange a special supervision with the care worker involved. The aim of the supervision is to review the circumstances and identify support needed.

Prior to the latest registered manager joining, the service would’ve simply asked the care worker to refresh their training rather than focus in on the specific issue that caused the incident. However, it was found that with effective supervision, this wasn’t needed, and the manager can help to correct their practice.

Care provider: Anonymous

  • Case study

Date published: April 2018


Instant access to electronic MARs records

People’s medicine administration records (MARs) are now documented electronically on the providers’ electronic care records system. Care workers have instant access to information about people’s medicines and are kept informed of any changes, such as commencing antibiotics. The system reduces the risk of errors by providing up-to-date information.

Care provider: Anonymous

  • Case study

Date published: April 2018



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