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East of England, London, South Central & South East Coast
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Medicines Use and Safety
Audit Tool to assess Pharmacy Support for Community Health Services
Background
This ‘Audit Tool to assess pharmacy support for Community Health Services’ has been updated in 2012, now published as version 3, to reflect both organisation
change within the NHS, the Regulator and other organisations, and changes in the way services are now being provided. The aim of the Audit Tool remains the same,
which is to help organisations to identify gaps in pharmacy support for Community Health Services (CHS) and it could also be used to assess pharmacy support for
services from alternative providers.
(Note: version 1 was developed in 2004 and version 2 in 2008)
The aims of the Audit Tool are:
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To support organisations in assessing current levels of pharmacy support to services that they directly manage and/or commission
To support organisations in assessing the level of pharmacy support that they will need in the future
To contribute to the evidence collated for ‘The Essential Standards of Quality and Safety’, and for other regulatory bodies.
To provide a framework for identifying any risks and subsequent action planning
To support audit of provider services commissioned from other organisations
To gather evidence when making a business case to strengthen pharmacy support for Community Health Services
Preparation and completing the Audit
Experience from the original pilots showed that the audit was most useful when as much data as possible was collected prior to the audit by the Lead pharmacist
and/or the dedicated CHS pharmacist or member of the pharmacy team with responsibility for CHS. This should involve discussion with other key ‘stakeholders’ as
necessary e.g. recipients of the service such as key service managers and pharmacists and/or pharmacy technicians providing CHS support whether ‘in house’ or
within a SLA/contract. It is important to have relevant SLAs and/or service specifications in contracts, available for reference. It is recommended that the ‘auditors’ read
through the tool before conducting the audit to give them an opportunity to discuss any queries with a member of the CHS specialist pharmacy team (see Appendix 1
for contact details).
It is suggested that a senior pharmacist from the medicines management/pharmacy team (with the CHS pharmacist where possible) along with someone from e.g. the
provider’s clinical governance team jointly complete the self-audit. This will allow informed collection of data/information by a competent pharmacist as well as injecting
an element of objectivity.
©East & South East England Specialist Pharmacy Services
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Future revision of this Audit Tool
Please contact one of the MUS team (see Appendix 1) if you have any comments or suggestions for improvement.
Contents
Section A
Summary description of Community Health Services & management arrangements for pharmacy support –this section maps the CHS services
and the arrangements for pharmacy support.
Section B
Community Health Services pharmacy support and activity –this section looks in more detail at who is providing pharmacy support, accountability,
performance indicators and qualitative aspects of the service and personnel. Supporting evidence and proposed action to remedy any risks can be
recorded.
Section C
Qualitative data relating to Community Hospitals and other bedded services
Section D
Organisational governance arrangements in relation to medicines management in Community Health Services
Appendix 1
Contact details of the Community Health Services Specialists- Medicines Use and Safety Division, East and South East England Specialist
Pharmacy Services
References
Useful references and supporting information
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Section A Summary description of Community Health Services and management arrangements for pharmacy
support
List all the community health
services currently provided where
medicines are prescribed,
administered and/or supplied
Number of
bases and sites
Management arrangements. Is this via
A=Pharmacy staff directly employed by the
provider organisation,
B=Service level agreement e.g. with an acute
trust, Mental Health Trust
C=Primary Care Trust pharmacy team or
successor team/organisation
D=Clinical Commissioning Group or
E=Other provider
For SLA and ‘other’ state name of the
provider organisation. When there is more
than one arrangement for a service, record
details for each one e.g. for each community
hospital
Briefly describe the pharmacy support
provided for these services i.e.
1=Professional advice and query answering
2=Clinical pharmacy service e.g. prescription
monitoring
3=Support with policies/procedures,
4= Support for Education & Training of
provider staff
5=Input to practice committees such as
Medicines Management Group, Drug &
Therapeutics Group, Immunisations group etc
6= Input to clinical governance & risk
management e.g. National Reporting and
Learning System, The Essential Standards of
Quality and safety
7=Procurement & supply of medicines
8=Dispensing of medicines
9=Support for Patient Group Directions, Non
Medical Prescribers
10=Audit & monitoring of medicines handling
11=Provision of financial information on
medicines usage
12=Support for services provide by
Pharmacists with Special Interests or similar
specialists
A1 Community Adult /District nursing
A2 Children’s services/Public Health
Nursing to include
Health visiting and School Nurses
A3 Community Children’s nursing
A4 Contraception and Sexual Health
Services, and HIV services
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A5 Chiropody/podiatry including
Podiatric surgery
A6 Dentistry
A7 Bedded services e.g. beds
managed by community health
services, Community hospitals
A8 Learning disability services
A9 Minor Injuries Unit, Urgent Care
Centre, Walk in Centre
A10 Out of Hours Service
A11 Specialist community teams e.g.
tissue viability, Teams providing care
closer to home, Teams providing
intravenous medicines in the
community etc.
A12 Community matrons
A13 Allied Health Professional (AHP)
led services e.g. Physiotherapy-led
‘injection’ clinics, dietetics, community
neuro-rehabilitation.
A14 Support for immunisation &
vaccination e.g. school- based
immunisation programmes, TB
services, Influenza vaccination
programmes
A15 Services provided by ‘Home Care’
companies
A16 other services
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Section B
Medicines Use and Safety
Community Health Services pharmacy support and activity
Criteria relating to pharmacy support and
activity
B1 Is a senior pharmacist routinely involved in
the strategy for and development of all
services that involve medicines management?
(see also D1)
Yes/No/partial
Data/evidence
Action plan
B2 Are there named pharmacy staff directly
employed by the organisation or
commissioned within SLA/contract who
provides advice and support to CHS as
part/all of their role?
B3 Are Job Descriptions, person specifications
& KSFs in place appropriate to the needs of
CHS and, are accountability arrangements
clearly described within SLAs & contracts?
B4 Are competencies of CHS pharmacy staff
appropriate to the needs of the services with a
performance appraisal system in place? (Ref
4 link to PCCPN competency framework )
B5 Are the following performance indicators
available to the commissioner to demonstrate
evidence of compliance with the relevant
outcomes of ‘The Essential Standards of
Quality and safety’?
 An overarching medicines policy is in
place or there is an index of the
organisation’s policies & procedures
covering all aspects of medicines use
 For contracted services/SLAs,
medicines practice meets the standard
required by the contracting
organisation
 Evidence of SOPs in place for every
aspect of medicines handling within all
services where medicines are in use
including CDs
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Medicines Use and Safety
Service developments where
medicines are involved, have
pharmacy input
Financial reporting on medicines use
to CHS service managers is in place
Records of advice etc e.g. medicines
information enquiries answered
Audits of medicines security and safe
handling of medicines
Audits of security and safe handling
of Controlled Drugs
Reporting of incidents involving
medicines
Evidence of implementation of
national guidance involving medicines
e.g. NPSA alerts medicines safety
alerts, NICE
A robust process for the drawing up
& approval of PGDs in accordance
with MHRA guidance
Other indicators are available e.g.
contribution to clinical governance such
as implementation of PGDs, audits,
assessment of training needs for other
CHS professionals and provision of
training etc.
B6 Are major interventions, and medicationrelated incidents, recorded and the learning
shared?
B7 Are medicines-related competencies
included in induction and in-service training
for nurses and other staff involved with
medicines?
B8 Partnership working
Is there a contract/SLA for social services and
social care providers to access advice and
support for medicines management from
CHS?
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B8a IF yes above, what support is currently
provided?
B9 Can local education services access
advice and support for medicines
management in schools?
B9a What support is currently provided?
B10 Is pharmacy support reflected in the
business/service plan of the individual/ team
responsible for leading on specific services
within CHS?
B11 Is there pharmacy representation on key
committees/working groups that impact on
pharmacy support to CHS (e.g. immunisation
and vaccination, contraception & sexual
health services or is there a specified
communications route?
Criteria relating to services commissioned
within SLAs and/or contracts
B12 Is there clear accountability of pharmacy
staff providing CHS defined within the
SLAs/contracts?
B13 Does the SLA contain Key Performance
Indicators and are all provider services within
SLAs/contracts regularly monitored and at
least annually?
B14 Does a senior pharmacist advise on the
monitoring criteria and/or input to monitoring
meetings?
B15 Is there a dedicated telephone contact
number for pharmacy staff e.g. where the
pharmacy service to a community hospital is
contracted out, can the hospital staff readily
access pharmacy advice?
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B16 Are there effective communication
channels between providers and recipients of
the service to enable effective cascade of
information?
B17 Are there satisfactory cover
arrangements for leave etc.?
Is there a business continuity plan?
B18 Are there appropriate working
arrangements including access to the internet,
email electronic data- bases and other
resources for CHS staff including, for
example, Medicines Information services?
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Section C Qualitative data relating to Community Hospitals and other bedded services
Topic
C1 Type of bedded service (include details
of whether managed by of for, CHS, other
NHS, private or voluntary sectors)
Elderly Care
Yes/No/partial
Data/evidence
Number of beds & hours of clinical pharmacy/
week
Action plan
Rehabilitation
Intermediate care/sub-acute/step-down
Day hospital
Learning Disability
Palliative care
Other
C2 Is the service provided comparable to that
provided to similar beds in a local acute
hospital e.g. in terms of allocated time,
frequency and competency of individual
pharmacists
Is the service consistent across the local
healthcare economy?
C3 Does the clinical service include?
 Prescription monitoring
 Advice & information to staff re
pharmaceutical issues
 Other support e.g. audits, policies &
procedures, Education & Training
C4 Is the dispensing and supply service
provided under the same arrangement as the
clinical service?
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C5 Is there a system for prescribers to access
advice from a pharmacist?
C6 Is there a system to enable the pharmacist,
prescribers and other staff to communicate?
C7 Is there appropriate pharmacy input into
discharge planning/transfer of care, and
rehabilitation?
C8 Is there a procedure on admission for
patients own medicines to be checked for
suitability for use?
C9 Is Medicines Reconciliation (NICE/NPSA)
being implemented? What role does the
pharmacist have?
Note: You may find it useful to complete Section C for each type of bedded service separately
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Section D Organisational governance arrangements in relation to medicines management in Community
Health Services
Governance criteria
D1 Is there an accountable person at Board
level, through delegation from the Chief
Executive, for compliance with legislation and
NHS directives relating to the organisation’s
prescribing and medicines management
services
Yes/No/partial
Data/evidence
Action plan
D2 Is there professional pharmaceutical
leadership and the development and
implementation of a medicines management
strategy for the organisation
D3 Does the organisation have an Accountable
Officer (AO) for Controlled Drugs? If the
organisation cannot legally appoint an AO, Is
there a nominated individual who links with the
PCT’s Accountable Officer (AO) for Controlled
Drugs
D4 Is there an appropriate internal governance
route for approval of medicine-related policies
and procedures, incident reports, risk
assessments and assessment of compliance to
national standards and directives e.g. NICE,
NPSA
D5 Is there an appropriate internal governance
route for approval of Formulary decisions and
monitoring of prescribing and medicines
expenditure
D6 Is there a governance route for approval of
non-medical prescribing applications and for
Patient Group Directions. development of
PGDs along with the pharmacist and the
clinicians using the PGD
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D7 Is there representation on the Area or Local
Health Economy Prescribing
Committee/Medicine Management group or
equivalent, to maintain relationships with other
providers and promote consistent policies
across the local health economy e.g. managed
entry of new drugs, antibiotic prescribing
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Appendix 1
Contact details for the Community Health Services Specialists, Medicines Use and Safety Division, East and South East England, Specialist Pharmacy Services
Eileen Callaghan
Associate Director, Community Health Services
Tel 020 8274 6223
eileen.callaghan@croydonpct.nhs.uk
Tracy Rogers
Associate Director, Community Health Services
Tel: 01474 360601
Mob: 07770 700 836
Tracy.rogers@nhs.net
Tracy.rogers@kentcht.nhs.uk
Sandra Wolper
Associate Director, Community Health Services
Tel: 0208 630 3996
Fax 0208 630 3291
Mob 07957 202 353
sandra.wolper@hrch.nhs.uk
References and supporting information
1. Care Quality Commission: The Essential Standards of Quality and Safety
http://www.cqc.org.uk/organisations-we-regulate/registered-services/guidance-meeting-standards
2. The Rough Guide to Community Health Services
http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/Leadership-workforce/Resources-support-staff/TheRough-Guide-to-Community-Health-Services2/
3. Audit Commission “A Spoonful of Sugar” Medicines Management in NHS Hospitals 2001
http://www.audit-commission.gov.uk/nationalstudies/health/other/Pages/aspoonfulofsugar.aspx
4. Competency framework for pharmacy staff supporting community health services
http://www.pccpnetwork.nhs.uk
5. Building a safer NHS for Patients-Improving Medication Safety A report by the Chief Pharmaceutical Officer
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4071443
6. National Service Framework for Older People-Medicines booklet
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008020
7. Medicines in Commissioning-a toolkit
http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/Meds-use-and-safety/Commissioning/Meds-mngmnt-services/Medicinesin-Commissioning-Toolkit-Vs4/
8. NICE and NPSA technical patient safety solutions for medicines reconciliation on admission of adults to hospital
http://www.npc.nhs.uk/improving_safety/medicines_reconciliation/
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