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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.

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


8 example(s) found

Using PRN medicines safely and consistently

The service had robust arrangements for managing PRN (as-needed) medicines, supported by detailed, person-centred protocols. These clearly explained when medicines should be given, the signs that indicated a person might need them, and alternative approaches staff should try before administering medication. The guidance ensured staff responded consistently and helped reduce the risk of unnecessary medicine use. Staff also demonstrated a good understanding of how to monitor whether PRN medicines had been effective and when further advice from healthcare professionals was required. This structured approach supported safe, consistent and person-centred medicines management.

Read more about this service .

Care provider: Flora Innes House

  • Case study

Date published: June 2026


Strengthening medicines safety through robust systems

The service had comprehensive systems in place to ensure medicines were managed safely and consistently. Medicines were checked on receipt, with regular stock and balance checks completed to maintain accuracy. Topical medicines were clearly documented on medicine administration records and supported by body maps, helping to reduce the risk of errors. Storage temperatures were monitored and recorded to ensure medicines remained safe for use, while accurate records were maintained for medicines administered during off-site visits. Clear processes were also in place to report, review and learn from medicines incidents, reinforcing a strong culture of safety, accountability and continuous improvement.

 Read more about this service .

Care provider: The Old Orchard

  • Case study

Date published: June 2026


Real time eMAR and oversight

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. The provider had made clear improvements since the last inspection. Records were accurate and updated when people’s medicines changed. Staff completed training and the registered manager ensured all responsible staff had their competency assessed. With the provider’s updated digital monitoring system that had been implemented since the last inspection, medicines information was monitored in real time. Samples of electronic medicines administration records (eMAR) showed the management team was alerted and took appropriate action if any medicines task had not been completed.

Read more about this service .

Care provider: UK Prime Care Services

  • Case study

Date published: December 2024


Competent, STOMP aware medicines oversight

Staff were able to describe in detail how they administered people’s medicines. Staff correctly described the procedures to follow if a medicines error occurred. They were able to confidently tell us how to administer as required (PRN) medicines. Staff who administered medicines confirmed they have had medicines competency assessments carried out.

The manager was able to tell us how they ensured medicines were managed safely. They told us they maintain oversight of the use of sedative / anti-psychotic medicines. The said, “People are supported to have annual medicines reviews with their general practitioner (GP). As an organisation, we have Stopping the over medication of people with a learning disability (STOMP) forums. People we support are on our campaign to change. We have ambassadors and accessible information. The quality assurance audits check for evidence to support STOMP. One of my actions is to raise awareness of medicines within the service.”

Read more about this service .

Care provider: 231 Brook Lane

  • Case study

Date published: October 2024


Safe, competent medicines management

Medicines were ordered, checked and available when people needed them. Medicines were stored, administered, recorded and disposed of safely. Staff were trained and assessed as competent to administer medicines. Robust processes were in place to ensure people received their medicines in line with their prescriptions. The pharmacist told us staff were skilled at identifying any concerns regarding medicines and would raise this promptly to look at what adjustments could be made. This supported people’s safety and well-being. Staff were confident and knowledgeable regarding the medicines they were administering and demonstrated a skilled approach in supporting people. We spot checked medicines against stock lists, we found no concerns.

Read more about this service .

Care provider: Manor Lodge

  • Case study

Date published: September 2024


Proactive, confident medicines administration

Staff and the management team told us that some people required support to manage and administer their medicines. They confirmed that regular monitoring and audits were completed by way of checking people’s medication administration records (MAR), spot checks and feedback from clients and their representatives. All the staff we spoke with confirmed they had completed training for medicines management and administration and were confident with this area of responsibility. Staff also understood their responsibility for reporting problems or errors with people’s medicines. One member of staff told us, “I will call the GP if they are still open, if not 111, and discuss the situation; call the office and let them know and follow the instructions given to me. Then I will note in feedback and follow up.” Other staff members made comments such as, “I am very confident towards all clients with their medication.” And “Very confident and if l have any problems l will call the office.”

Read more about this service .

Care provider: London Care (Westminster)

  • Case study

Date published: June 2024


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



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