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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 3 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked response
Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
Betsi Cadwaladr University LHB
Conduct a formal internal investigation to identify root causes and lessons learned.
Betsi Cadwaladr University LHB
Disseminate the internal investigation’s lessons to all district nursing teams.
Betsi Cadwaladr University LHB
Conduct and document medication reviews at every local district nursing visit using a checklist countersigned by the care home.
Betsi Cadwaladr University LHB
Survey all district nursing teams to assess compliance with consistent medication-review practice.
Betsi Cadwaladr University LHB
Develop or adapt district nursing standard operating procedures and checklists to assure medication reviews.
Betsi Cadwaladr University LHB
Discuss with the Clinical Effectiveness Team how to audit medication-review changes over the longer term.
Betsi Cadwaladr University LHB
Review a proposal for structured medication-review collaboration between Central Community Pharmacy and the Central Community Resource Team.
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.
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.
Linked response
Orchard Care Homes
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Orchard Care Homes
Have the duty nurse accompany GPs on rounds and review medication administration charts and care plans to share relevant information.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.