First reported 14 Jul 2016•Latest report 14 Apr 2022
Definition
What this concern includes
Includes failures of care-home processes for checking or scrutinising residents' medication, including unclear or variable checking frequency and failure to conduct required medication review during care-home visits.
Not included
Excludes medication prescribing, dispensing, administration or supply failures where the care-home medication-checking process is not the unsafe condition.
Excludes generic staffing, training, documentation or governance deficiencies unless they directly cause unreliable medication checking in care homes.
Excludes clinical medication review outside care homes unless the assertion explicitly concerns the same care-home medication-checking process.
Excludes failures limited to acting on a medication problem after a reliable check has been completed.
Reports
3
Distinct published reports
Individual concerns
3
A report can raise multiple concerns
Date range
2016–2022
First to latest report issue date
Stated actions
8
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.
Alexander Court Care Centre1
Betsi Cadwaladr University LHB1
Department of Health and Social Care1
Local health board1
Ministerial department1
Nursing home1
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.
North Wales (East and Central)
Concerns raised1
Absence of proper medication scrutiny or review during each care home visit
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 concerns
Each 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.7
Action
Conduct a formal internal investigation to identify root causes and lessons learned.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Disseminate the internal investigation’s lessons to all district nursing teams.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Conduct and document medication reviews at every local district nursing visit using a checklist countersigned by the care home.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Survey all district nursing teams to assess compliance with consistent medication-review practice.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Develop or adapt district nursing standard operating procedures and checklists to assure medication reviews.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Discuss with the Clinical Effectiveness Team how to audit medication-review changes over the longer term.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2022.
Action
Review a proposal for structured medication-review collaboration between Central Community Pharmacy and the Central Community Resource Team.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Manchester South
Concerns raised1
Lack of a statutory definition of the required frequency of medication checks by care homes
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London (East)
Concerns raised1
Failure of General Practitioners to review and approve care home residents’ Medication Administration Records
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 concerns
Each 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
Action
Have the duty nurse accompany GPs on rounds and review medication administration charts and care plans to share relevant information.
Stated by Orchard Care HomesStated completedThe respondent said that this action was complete when they made their response on 14 July 2016.
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Includes failures of care-home processes for checking or scrutinising residents' medication, including unclear or variable checking frequency and failure to conduct required medication review during care-home visits.
