Medication Management in Care Homes: CQC Standards and Audit Essentials

This guide provides general information on medication management governance in care homes. It does not replace clinical advice from a pharmacist, prescriber, or your local medicines optimisation team. Always follow your dispensing pharmacy's guidance and your own local policies for specific medication decisions, particularly for controlled drugs and covert administration. References to NICE guidelines and legislation are current as of the last reviewed date above — verify against NICE and legislation.gov.uk for the latest position.

Medication errors are among the most common safety incidents in care homes, and medication management is one of the areas CQC scrutinises most closely. The combination of complex polypharmacy (many care home residents take 8 or more medicines), frequent prescribing changes, and reliance on staff who may have limited pharmacological training creates a high-risk environment that demands rigorous systems.

This guide covers the regulatory framework, what CQC expects, how to audit effectively, and the common findings that trip care homes up.

The regulatory and guidance framework

Several interlocking pieces of legislation and guidance govern medication management in care homes:

Regulation 12(2)(g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires the "proper and safe management of medicines." This is the legal baseline CQC enforces.

NICE SC1 (Managing medicines in care homes) — published March 2014, updated 2023 — is the primary practice guideline. It covers the entire medicines pathway from prescribing to administration, storage, disposal, and review. CQC assessors reference SC1 frequently in inspection reports.

NICE NG67 (Managing medicines for adults receiving social care in the community) — published March 2017 — complements SC1 with broader guidance on person-centred approaches to medicines and shared decision-making.

The Misuse of Drugs Act 1971 and The Misuse of Drugs Regulations 2001 govern controlled drugs (CDs). Schedule 2 drugs (morphine, fentanyl, oxycodone) require the most stringent controls. The Controlled Drugs (Supervision of Management and Use) Regulations 2013 established local intelligence networks (CDLINs) and accountable officers.

The Human Medicines Regulations 2012 cover general medicines legislation, including who can administer medicines and under what authority.

Understanding which framework applies to which aspect of your medication management is essential for building a compliant system.

What CQC expects: the essentials

Medication Administration Records (MAR charts)

MAR charts are the primary evidence of medication administration. CQC assessors will review a sample of MAR charts during every inspection. They check for:

Resident details — full name, date of birth, GP name, known allergies (including NKDA — no known drug allergies, documented explicitly)
Photograph — current photograph of the resident on the front of the MAR chart to prevent wrong-patient errors
Prescribed medicines listed accurately — name, dose, form, route, frequency, and any special instructions
Administration codes — every dose slot completed with a signature or a code explaining why the medicine was not given (e.g., R = refused, H = in hospital, D = destroyed/discontinued by prescriber)
No unexplained gaps — a blank space on a MAR chart is a medication error in CQC's view because it is impossible to determine whether the medicine was given, omitted, or simply not recorded
PRN (as required) protocols — for PRN medications, a separate protocol documenting the indication, dose range, maximum frequency, route, and what to monitor after administration
Handwritten entries — where medicines are handwritten onto a MAR chart (e.g., mid-cycle prescribing changes), the entry must be signed by two members of staff and countersigned by the prescriber or pharmacist at the earliest opportunity

Controlled drugs (CDs)

Controlled drug management attracts particular scrutiny. Requirements include:

CD register — a bound book (not loose-leaf) with entries in ink, showing date, quantity received, quantity administered, running balance, and signatures of two staff for every transaction
Stock checks — balance in the CD register checked against physical stock at every shift handover (twice daily at minimum). Both staff sign the register to confirm the balance.
Storage — Schedule 2 and 3 CDs stored in a locked cabinet that is fixed to a wall or floor, within a locked room. The cabinet must meet BS 2881:1989 or equivalent.
CD destruction — expired or discontinued CDs destroyed in the presence of an authorised witness (pharmacist or CD accountable officer representative). Recorded in the CD register.
Discrepancies — any discrepancy between the CD register balance and the physical stock investigated immediately, documented, and reported to the CD accountable officer at your local ICB.

Medication storage

General medication storage requirements:

Locked medication trolley or room, with restricted key access
Room temperature monitored daily (medicines stored below 25°C per manufacturer instructions)
Fridge temperature monitored daily (2-8°C for cold-chain items such as insulin, eye drops, some liquid antibiotics). Maximum/minimum thermometer used, records kept.
Medicines within expiry date — opened liquids dated when first opened and discarded per manufacturer guidance (typically 28 days for oral liquids unless otherwise stated)
External medicines stored separately from internal medicines
Medication not taken to communal areas ahead of rounds

Medication reviews

NICE SC1 recommends that all care home residents have a structured medication review at least annually, conducted by a pharmacist or prescriber. For residents taking 10+ medicines, or those with complex needs, more frequent reviews are appropriate.

Document in the care plan:

Date of last medication review
Who conducted it
Outcomes and any changes made
Date of next planned review

CQC assessors will check whether medication reviews are happening and whether the outcomes are actioned.

Auditing medication management

Monthly medication audits are standard practice. Your audit should cover:

MAR chart accuracy audit

Sample 10-20% of MAR charts (or all, if your home has fewer than 20 residents)
Check every dose slot for the previous month — no gaps, correct codes used
Verify allergies are documented and current
Check PRN protocols exist for all PRN medicines
Verify handwritten entries are correctly countersigned
Calculate your medication administration error rate (target: below 5% non-administration without a documented reason)

Controlled drugs audit

CD register checked against physical stock (full count, not just running balance)
All entries complete — no gaps, corrections made correctly (single line through the error, dated and signed, not correction fluid)
Destruction records complete and witnessed
Register reviewed for any patterns (e.g., consistent over-ordering, frequent discrepancies)

Storage audit

Room temperatures within range for the full month (check daily log)
Fridge temperatures within 2-8°C (check daily log — note and investigate any excursions)
All medicines in date
Opened liquids within their use-by period
Trolley/room locked when unattended
Keys held by authorised staff only

Process audit

Medication round observed — correct technique (right resident, right medicine, right dose, right route, right time)
Staff competency assessments in date (annual reassessment recommended per NICE SC1)
Covert administration recorded correctly (capacity assessment, best interests decision, and pharmacist advice documented for each medicine given covertly)
Homely remedies policy in place and followed (e.g., paracetamol kept for occasional use without a prescription — check that your policy complies with your pharmacy contract)

Common CQC findings on medication

These findings appear repeatedly in published CQC inspection reports:

"We found gaps on MAR charts where it was not possible to determine if people had received their medicines as prescribed." This is the single most common medication-related finding. It triggers a Regulation 12 breach in almost every case. The fix is straightforward — robust checking processes at the end of every medication round, with a second check at handover.

"PRN protocols were not in place for all as-required medicines." Every PRN medicine needs a written protocol. Without one, different staff may administer the medicine for different reasons, at different thresholds, and with different monitoring. This is especially critical for PRN pain relief and PRN psychotropic medication.

"The provider had not ensured all staff administering medicines had received competency assessments." Under NICE SC1, staff administering medicines should be assessed as competent at induction and reassessed annually. Keep a competency assessment record for every staff member who administers medication.

"Medicines requiring cold storage were found to be out of range." A single day where the fridge temperature exceeded 8°C and no action was taken is enough for a finding. If the temperature goes out of range, follow your protocol (quarantine affected stock, contact the pharmacist for advice on whether medicines remain usable, record the excursion and your response).

"The controlled drugs register contained several unexplained discrepancies." CD discrepancies are treated seriously because they may indicate diversion. Even small discrepancies (a single tablet) must be investigated, documented, and reported.

"People's medicines were not always reviewed in a timely way." Check that every resident has had a medication review within the past 12 months. Chase the GP surgery or community pharmacist if reviews are overdue — and document that you have chased.

Building a medication safety culture

Beyond auditing, CQC looks for evidence that medication safety is embedded in your culture:

Medication errors are reported, investigated, and learned from. Maintain a medication error log. Review it monthly. Look for patterns (same time of day, same staff member, same resident, same medication). Feed findings into training.
Near-misses are reported. A near-miss (e.g., picking up the wrong blister pack before checking the name) is a learning opportunity. If only actual errors are reported, you are missing prevention data.
Staff feel confident raising concerns. If a carer notices a medicine that does not look right, or a dose that seems unusual, they need to feel empowered to stop and check without fear of being seen as slow or difficult.
Pharmacist involvement is proactive. Your dispensing pharmacist should be more than a delivery service. Engage them in audits, staff training, and medication reviews. NICE SC1 (recommendation 1.15) encourages pharmacist involvement in care home governance.

Getting started

If your medication audit programme needs improvement, take these three steps:

Run a full MAR chart audit this month. Check every chart, every dose slot, for the past 28 days. Calculate your gap rate. This gives you your baseline.
Verify your CD processes. Conduct a full stock check against the register. Review the past 3 months of entries for completeness.
Check competency records. Confirm every staff member who administers medicines has a current competency assessment. Schedule reassessments for anyone overdue.

For help building medication audits into a structured schedule, see our guide on creating a care home audit schedule. For broader IPC audit guidance that overlaps with medication management (particularly around aseptic technique for injections and wound care), see our infection control audit guide. And for a complete overview of CQC requirements under the single assessment framework, see our CQC compliance guide for small care homes.