This report by the CQC brings together what they have discovered through their regulatory activity about the risks from medicines. It raises important issues for everybody involved with medicines   in all health and adult social care settings. There has been a lot of work to ensure safer use of medicines across services, but there are still areas to be improved. The CQC is keen that all health and care providers understand the risks, and are able to apply learning from these to  enable better outcomes for people using services.

Providers often state that examples of good practice are a useful tool to help them get thinking about the improvements they can make in their own services. The CQC’s  report shares some good practice and innovative ways of working. A separate, blog part 2, contains some of these examples.

The six most common areas of risk with medicines across health and care. 

1.   Prescribing, monitoring and reviewing

Guidance from the General Medical Council is clear that professionals are responsible for the prescriptions they sign and for their decisions and actions when supplying and administering medicines, or authorising or instructing others to do so. Prescribers and pharmacists supplying medicines have a responsibility to keep patients safe and to tell them about any risks in using a medicine. Carrying out timely medicines reviews is also key to ensuring that people’s medicines remain both safe and effective.

Monitoring patients is an essential component of the prescribing process. This covers the initial prescribing to how people’s medicines are monitored over the long term to  ensure  that they remain safe and effective. The CQC found many examples of risk and unsafe practice across a range of health and social care settings.

2.   Staff competence & workforce capacity

The CQC analysis showed that staff were not always trained and assessed as competent to carry out aspects of their roles. This applied to both health and social care settings. In some examples, there were not enough competent staff in both domiciliary home care and residential care home settings to administer medicines to people.

The concept of ongoing monitoring and assessing competency, particularly after medicines administration errors, was not implemented in some organisations. The CQC analysis also revealed examples of services that did not have enough staff to carry out basic duties, such as essential monitoring after administering certain medicines, and carrying out medicines reconciliation.

The analysis also highlighted other common areas that contribute to risks, which affect medicines optimisation as a whole across all sectors. For example, having good governance (effective audit, policy and procedures, and incident reporting) and keeping clear and accurate records.

3.   Supply, storage & disposal

Problems with the supply of medicines could be linked to both prescribing and to problems with stock ordering and control. The CQC found that a wide range of medicines were not always  stored appropriately, including intravenous fluids and controlled drugs. They also found that some medicines were not stored at the manufacturer’s recommended temperature, which can compromise their effectiveness and pose a risk to patient safety

4.   Administration

Issues with administration were commonly linked to poor record keeping, which included incorrectly transcribed medicines administration records and failure to record administration.

5. Transfer of care

Through their regulatory work in health and care services, the CQC has seen an increased risk of poorer experiences and outcomes when people’s care is transferred between services.

The CQC found examples where people’s safety was put at risk when they had been discharged from hospital to care homes, or to their own home, without any guidance on how to take  medicines, or in some cases without a supply of medicines at all. They also saw examples of unsafe care when information about changes to medicines was either not transferred soon enough, not accurate or not transferred at all.

6.   Reporting and learning from incidents

Reporting incidents and near misses, and sharing the learning from them, is crucial to reduce the risk of a similar event happening again. The CQC analysis showed that medicines incidents were not always recorded, and low recording rates were sometimes associated with a culture of fear within organisations about reporting mistakes. They also found examples of providers who lacked the insight to investigate and share learning within their organisations.

Antibiotics and antimicrobials

Specific issues around prescribing and administering antibiotics were uncovered in the Inspection Reports and revealed examples where antimicrobials were:

  • not prescribed on time for people with suspected sepsis or meningitis
  • not prescribed correctly
  • not administered correctly, including at the correct intervals and ensuring that the patient completed the prescribed

Transdermal Patches

ProRisk Care Consultancy wishes to draw attention to this very common problem which is a major issue.

The correct application of transdermal patches and the evidence of appropriate patch rotation as detailed in the PIL (patient information leaflet).
In many services that we have reviewed, there has been incorrect rotation of patches and this has been picked up by the CQC as a medication fail in their reports.
Rivastigmine patches in particular require rotation over 8 sites before re-application in the same area. Follow this link

All transdermal patches need fully documented information, detailed on patch application charts which show the location of patch application and removal of the patch along with a rotation plan for staff to follow using a numbering system which is auditable and trackable over time.

OPUS Pharmacy Services have a number of free downloads such as template audits, PRN protocols, topical cream risk assessment and competency assessments. Opus also provide bespoke and distance learning for staff.


Specifically for Adult Social Care

In their analysis they identified several key themes pertinent to providers of adult social care,  which included errors in medicines administration and record keeping, and managing ‘when required’ (PRN) medicines

These findings are based on an analysis of 55 inspection reports (including a mix of care homes, care homes with nursing and domiciliary home care services for older people and people with a learning disability), 50 enforcement notices and 405 statutory notifications

Did you know that the CQC has a national Medicines Optimisation Team of pharmacy professionals who take ownership for all aspects of medicines in the regulatory context? This   team works across the country providing specialist advice on the use of medicines in all settings.

Example of poor practice in the use of PRN medicines

“In our analysis, we found examples of how poor practices around PRN medicines could adversely affect people’s quality of life. On one inspection, we saw that medicine protocols for pain relief were not person-centred and lacked sufficient detail for staff to know if the person needed their medicine. Where people could not communicate to let staff know if they were in pain, there were insufficient guidelines in place for staff to provide consistent treatment.”


Actions for adult social care providers

Based on the risks identified with medicines use in adult social care settings, the  CQC  encourages 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, pharmacy professionals and healthcare professionals.
  2. Providers of adult social care should consider having an attached or named pharmacist to support staff with issues around the use of medicines. 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
  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
  4. Identify 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
  5. The new role of nursing associate will 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
  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.

Full report can be found here: 20190605_medicines_in_health_and_adult_social_care_report.pdf