Recurring concern
Unreliable medication management in care homes
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Request correctionFirst reported 28 Feb 2014•Latest report 30 Jan 2026
What this concern includes
Includes care-home failures in medication governance and management, including medication policies and procedures, prescribing or administration controls, access restrictions, documentation, checking, monitoring and escalation where these directly concern safe medication use for residents.
Not included
- Excludes medication failures outside care-home resident medication management unless the assertion explicitly concerns the same care-home process.
- Excludes generic staffing, training, communication or record-keeping deficiencies unless they directly impair safe medication management in a care home.
- Excludes medication supply, prescribing, dispensing or administration concerns governed by a more specific established medication-safety parent when the narrower concern is the better boundary.
- Excludes clinical treatment or monitoring failures unrelated to medication management.
- Reports
- 11
- Individual concerns
- 15
- Date range
- 2014–2026
- Stated actions
- 13
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Lack of medication policies
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Complete and consolidate operational policies covering medication, infection control, incidents, escalation, safeguarding, concerns and hospital discharge.
Stated by Premiere Health Limited -
Action
Store operational policies centrally in a digital governance system accessible to all staff.
Stated by Premiere Health Limited
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Concerns raised3
Failure to clarify medication changes before continued administration
Lack of clear procedures for medication management when a discharge letter cannot be located
Failure to escalate medication uncertainty to appropriate clinical advisers
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Introduce and disseminate a visual flow chart guiding staff through medication checks when residents return from hospital without discharge documentation.
Stated by Care UK -
Action
Reinforce hospital-return, discharge and medication-management policies through mandatory read-and-sign confirmation and refresher training.
Stated by Care UK -
Action
Train staff to escalate hospital-return medication queries, obtain same-day clarification and document communications, actions and handovers.
Stated by Care UK
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Action
Discuss imminent and new hospital discharges at daily and weekly clinical meetings so required information and follow-up actions are identified.
Stated by Care UK -
Action
Continue working with hospital Trusted Assessors to streamline secure, prompt sharing of discharge information and support safe transitions of care.
Stated by Care UK
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Concerns raised1
Lack of a protocol for medication oversight after client falls
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to supervise syringe medication
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Conduct weekly observations of medicine rounds.
Stated by Four Seasons Health Care Group -
Action
Write and share a specific medication risk assessment when medication-management risk is identified, retaining it with medication records.
Stated by Four Seasons Health Care Group
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Concerns raised1
Failure to check oramorph medication contents before handing it over
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Review and revise medication policies, procedures and working practices to prevent recurrence of medication-related incidents.
Stated by Cherish Homecare Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The existing approach to handing items to service users with capacity, without routinely checking contents, remains appropriate.
Stated by Cherish Homecare Limited
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Position
Medication management was outside the commissioned care responsibilities, so the service user was expected to manage her own medication.
Stated by Cherish Homecare Limited
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Concerns raised2
Poor management and documentation of medication
Failure to prevent unauthorised access and repeated administration of Oramorph
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Implement the Controlled Drugs Regulations establishing tighter controls and mandatory governance arrangements for prescribing, records, custody, monitoring and accountable officers.
Stated by Department of Health and Social Care -
Action
Accelerate rollout of electronic prescribing for controlled drugs and medicines administration.
Stated by Department of Health and Social Care -
Action
Deploy additional clinical pharmacists in primary care and care homes.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing controlled-drug governance measures are considered sufficient to detect and minimise inappropriate use, although they cannot prevent every incident.
Stated by Department of Health and Social Care
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Position
Registered providers and managers are responsible for ensuring the proper and safe management of medicines in care homes.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of care home records to document conditions, symptoms and medication purposes
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to account for and query excess resident medication
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Unauthorised medication or prescription of ineffective remedies by non-medically qualified care staff
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification
Failure of care home management to identify carers’ non-compliance with drugs administration protocols
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026