When a residential care home in the East of England contacted AJR MedSafe Academy, it was around eight weeks away from an expected CQC inspection. The registered manager was confident about the care being delivered but wanted independent reassurance that the home’s medicines systems would stand up to scrutiny — and a clear, practical plan for anything that needed to improve.

This case study explains how a structured pre-CQC medicines compliance audit, followed by targeted medication training and individual Knowledge & Understanding Assessments, helped the home close key risks and walk into its inspection prepared and confident.

The challenge

The home supported around 30 older people, several of whom were prescribed high-risk or time-critical medicines, including controlled drugs. Like many services, the team was busy, staff turnover meant a mix of experience levels, and medicines paperwork had grown organically over time. The manager’s concern was a common one: “I think we’re doing the right things, but I can’t always evidence it clearly, and I don’t know what an inspector would pick up.”

Typical pressures included:

  • a mix of paper and electronic records that were hard to reconcile
  • uncertainty about whether PRN (as-needed) medicines had clear protocols
  • limited, inconsistent evidence of staff medicines competency
  • no recent independent review of storage, records and governance

Our approach

Rather than a generic checklist, we worked through the home’s medicines systems the way a CQC inspector would, then turned the findings into a prioritised, plain-English action plan.

1. Pre-CQC medicines compliance audit

Amelia Raby, a GPhC-registered Pharmacy Technician, carried out an on-site pre-CQC medicines audit for care homes. This reviewed MAR and eMAR records, medicines storage and temperature monitoring, controlled drugs storage and register balances, PRN protocols, covert administration arrangements, ordering and disposal, and the medicines-related evidence held in staff files.

2. A prioritised action plan

Every finding was rated by risk and paired with a clear, achievable action — so the manager knew exactly what to fix first, what was lower priority, and what was already working well. The aim was not to overwhelm the team, but to give them a realistic route to safer, better-evidenced practice.

3. Targeted training and knowledge assessment

We then delivered focused medication training built around the home’s real systems and the issues the audit had surfaced, followed by individual Knowledge & Understanding Assessments so the manager could evidence that staff had understood their medicines training.

What the audit found

The findings were typical of a well-run service that had simply never had an independent medicines review. Nothing suggested unsafe care — but several areas would have been difficult to evidence at inspection:

  • occasional unexplained gaps and unsigned entries on MAR charts
  • PRN medicines without consistent, written “when and why” protocols
  • medicines fridge and room temperatures not always recorded
  • controlled drugs balances that needed tighter, witnessed checks
  • thin or missing medicines competency evidence in some staff files

What we put in place

Working alongside the manager, we helped the home:

  • close MAR recording gaps and agree consistent use of codes
  • introduce clear PRN protocols for every as-needed medicine
  • embed simple, daily temperature monitoring
  • tighten controlled drugs checks and record-keeping
  • strengthen the home’s medicines competency records and identify any staff needing further workplace competency assessment
The outcome

Within a few weeks the home had strengthened its medicines records, closed the key risks identified in the audit, and could evidence safe practice clearly. Just as importantly, the manager and staff went into their CQC inspection feeling prepared and confident — not anxious about what might be found.

What clients say about our audits

“It is not only extremely helpful but the action plan makes our planning and thoughts so much clearer. We will be in touch again and thanks so much for your support so far — it has been invaluable.”

— Suzanne, Heywoods Grange

Could your service benefit from the same support?

Whether you are preparing for a CQC inspection or simply want independent reassurance about your medicines systems, AJR MedSafe Academy can help. Our Pharmacy Technician-led pre-CQC medicines compliance audit gives you a clear picture of your risks and a practical plan to fix them, backed by medication training and Knowledge & Understanding Assessments where needed.

Request a pre-CQC medicines audit for your care home, or book a discovery call with Amelia to talk through your service.

This case study is based on real audit and training work; details have been kept general to protect client confidentiality. Training and audit support can strengthen practice and evidence but cannot guarantee a CQC rating or inspection outcome.