Medication audits in care homes: why tick-box checks miss the risk that matters
A care home can have every MAR chart signed, every stock count correct, and every fridge temperature logged, and still be managing medicines unsafely. A medication audit that only checks whether boxes are filled in confirms that staff can complete a form. It doesn't confirm that a PRN dose was clinically justified, that a covert administration decision is still valid, or that a psychotropic medicine is still needed. Genuine medication audits have to check the decision behind the record, not just the record.
Table of contents
What a medication audit is actually for
Why 100% MAR chart completion isn't the same as safety
PRN protocols: the gap most audits skip
Covert administration: documentation versus justification
STOMP and psychotropic reviews: the audit blind spot
Building an audit that checks decisions, not just signatures
Why medication audits in care homes matter more than most other checks
Medicines errors remain among the most common safety incidents in adult social care, and medicines management is one of the areas CQC scrutinises most closely under Regulation 12(2)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which requires the proper and safe management of medicines. Providers audit medicines constantly. The question worth asking is whether the audit is actually finding anything, or just confirming that the paperwork exists.
What a medication audit is actually for
A medication audit exists to catch harm before it happens, not to prove a chart was signed. MAR chart checks, stock reconciliation and fridge temperature logs are necessary, but they're process checks. They tell you whether a system was followed. They don't tell you whether the clinical decisions inside that system, what to give, when, and whether it's still needed, were sound. CQC's own guidance on managing medicines for adults in community settings sets out that policies should reflect assessed need, clear prescriber directions, and staff who are trained and competent, which is a different question from "did they sign the box."
Why 100% MAR chart completion isn't the same as safety
A perfectly completed MAR chart audits the signing, not the decision. Gaps on a MAR chart are a genuine and common finding, and they matter because a gap means nobody can confirm a dose was given as prescribed. But the inverse isn't automatically true. A chart with every box filled in only shows that a member of staff pressed a pen to paper at the right time. It says nothing about whether a PRN dose was given for a documented reason, whether a covert administration decision still has a valid best-interests basis, or whether a medicine prescribed eighteen months ago has ever been reviewed since. An audit built entirely around chart completion will pass a service that has quietly stopped thinking about why it's giving what it's giving.
PRN protocols: the gap most audits skip
Every PRN (as-required) medicine needs its own written protocol, and most audits never check whether one exists for each medicine individually. CQC's guidance on when-required medicines requires clarity on what the medicine is for, how staff should recognise the need for it, and how effectiveness is reviewed. In practice, many services have a general PRN policy but no medicine-specific protocol for each resident's PRN item. A tick-box audit that asks "is there a PRN policy in place" will pass. A genuine audit asks "does this specific resident's PRN antihistamine, laxative or analgesic have its own protocol, and has anyone checked whether the frequency of use suggests the underlying condition needs reviewing instead."
A worked example
Consider a resident prescribed PRN paracetamol for occasional pain and a PRN sedative-type medicine for occasional agitation. A chart audit confirms both were signed correctly whenever given. A decision-level audit asks a different question: how often was the sedative actually used over the last month, was that frequency ever flagged to the prescriber, and does the general homely-remedies policy actually cover paracetamol under this service's specific pharmacy contract. That second layer of questioning is where risk usually lives, and it's rarely on a standard audit form.
Book a CQC Readiness Assessment and get a clear picture of where your medicines audit process stops at the paperwork and where it needs to go further, before an inspector asks the question first.
Covert administration: documentation versus justification
A completed covert administration record isn't the same as a current, valid justification for covert administration. Where medicines are given covertly, CQC and pharmacy guidance expect a documented capacity assessment, a best-interests decision, and pharmacist input for each medicine given this way. Audits commonly check that the paperwork exists at the point covert administration started. Far fewer check whether that justification has been revisited since, whether the resident's capacity has been reassessed, or whether the same reasoning still applies to every medicine on the chart rather than just the one it was originally written for. A stale covert administration decision, still being acted on months after the circumstances that justified it may have changed, is a live safeguarding and consent issue that a signature-focused audit will not surface.
STOMP and psychotropic reviews: the audit blind spot
Psychotropic medicines prescribed for behaviour that has since stabilised are one of the most common medicines-related risks that standard audits miss entirely. NHS England's STOMP initiative (stopping over-medication of people with a learning disability, autism or both) exists because psychotropic medicines are frequently continued well past the point of clinical need, often because nobody's audit process asks the question. A MAR chart audit confirms an antipsychotic was given as prescribed. It doesn't ask when that prescription was last reviewed, or whether the behaviour it was originally prescribed for is still present. Building a prompt for annual medication review, in line with NICE's SC1 guideline on managing medicines in care homes, into the audit cycle itself is what turns this from a hoped-for good practice into something that's actually checked.
Building an audit that checks decisions, not just signatures
The fix isn't a longer checklist, it's a different set of questions layered on top of the existing one. Keep the process checks (chart completion, stock counts, storage, disposal records); they're a genuine regulatory requirement and a real, if partial, safety signal. Add a second pass that asks, for a sample of residents each cycle: is there a written protocol for every PRN medicine this person has, has any covert administration decision been reviewed since it was first agreed, and when was this person's psychotropic medicine last formally reviewed against the reason it was started. None of those questions show up on a chart-completion checklist. All of them show up in a CQC inspection.
The counter-intuitive point is this: services with the cleanest-looking medicines audits are sometimes the ones where nobody has looked past the signature in a long time, precisely because the paperwork gives everyone permission to stop asking. The audit that finds problems is the one that's willing to look like it's failing something, at least on paper, in order to catch the thing that actually matters.
Verified sources
Care Quality Commission. Managing medicines: home care providers. cqc.org.uk
Care Quality Commission. Medicines optimisation, single assessment framework. cqc.org.uk
Care Quality Commission. When required (PRN) medicines in adult social care. cqc.org.uk
National Institute for Health and Care Excellence. Managing medicines in care homes (SC1). nice.org.uk
NHS England. Stopping over-medication of people with a learning disability, autism or both (STOMP).
FAQ
What's the difference between a medication audit and checking the MAR chart?
Checking the MAR chart confirms a process was followed: the right box was signed at the right time. A medication audit should also check the clinical decision behind the record, such as whether a PRN dose was justified, whether a covert administration decision is current, and whether a long-term psychotropic medicine has been reviewed.
How often should medication audits happen in a care home?
Process checks (MAR chart accuracy, stock counts, storage) are typically done daily or weekly. Decision-level reviews, such as PRN frequency review and psychotropic medication review, should happen at least as often as NICE's SC1 guideline recommends for structured medication reviews, and sooner if a resident's needs change.
Do PRN medicines need their own individual protocol?
Yes. CQC guidance on when-required medicines expects a written protocol for each PRN medicine, covering what it's for, how staff recognise the need, and how its use is reviewed, rather than a single general PRN policy covering every resident.
What does CQC actually look for beyond the MAR chart?
Alongside chart accuracy, CQC's medicines optimisation framework references PRN protocols, covert administration justification, and appropriate psychotropic prescribing (including STOMP principles) as part of safe medicines management. A tick-box audit that stops at chart completion won't evidence any of that.
Who should carry out a decision-level medication audit?
The registered manager remains accountable, but the review of whether a PRN pattern, covert decision, or psychotropic prescription still makes clinical sense is strongest when it involves the prescriber or a pharmacist, not just internal sign-off, in line with NICE SC1's emphasis on structured, professionally-led medication review.
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