Source:  CQC


Care Quality Commission (CQC) has published a report sharing the learning from risks and good practices in medicines, which they found in their inspections. CQC have seen that medicines can present a clear risk to people when not used properly.


When CQC inspects health and care services, they assess how well they meet people’s needs. As part of this, they 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.


CQC does 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 their analysis, CQC have categorised the most common areas of risk with medicines across regulated health and adult social care services. The report also examines what a number of these themes mean for adult social care. Their 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 their analysis, including medicines administration and record keeping.


CQC 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.


You can read the full report in more detail, along with CQC’s suggested actions for all health and social care providers, in the main report below.

» Medicines in health and adult social care report- Learning from risks and sharing good practice for better outcomes.


Medicines Administration

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 with all service types that CQC regulates, they 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.


CQC’s analysis also showed that providers need to consider their requirements when administering medicines covertly. They found that providers did not always comply with the Mental Capacity Act, or act on guidance on how to alter medicines safely. CQC 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.

» Read the full report