Medication safety in care homes for older people

Older people living in care homes often take several types of medication. They may communicate their needs and experiences in different ways. The people supporting older people living in care homes need to recognise how medication may be affecting their health, wellbeing and daily life.

Managing medication often involves several people and organisations working together, including residents, families and carers, care home staff, GPs, community pharmacists, hospital teams and community services. It can become more difficult when medication or information passes between services, or when roles and responsibilities are not shared or understood in the same way. Important medication may not be given, or changes to medication may not be understood or acted on.

HSSIB reviewed information about medication safety and spoke with people working across social care, health services and other organisations involved in providing medication.

We identified recurring issues where several organisations are involved, including differences in access to professional support, medication reviews, staff training, digital systems and learning. The investigations will explore how medication is managed in everyday practice, while recognising that care homes are people's homes and should support residents' choices, preferences and independence.

Local investigations

These will take place in different care homes for older people. Each will focus on a different medication safety issue and explore:

• how residents, families, care home staff and other services work together to manage medication
• what works well and what makes safe medication management more difficult
• how residents, families, carers and advocates are involved
• how concerns and experiences are reported, understood and used to improve care.

The three areas focus on medication safety when the care home resident

1. moves between care settings
2. needs time sensitive medication
3. needs “as required” (or PRN) medication

Wider review

This review will consider the issues identified through the local investigations and involve the people and national organisations connected with these three medication safety areas at the interface between health and social care.

Each local investigation report will be published when it is complete. The wider review will be published as the fourth report on this topic, expected to be Autumn 2027.

HSSIB investigations are independent and do not apportion blame or liability to individuals or organisations.

We want to hear from people with experience of medication use in care homes for older people. This includes residents, families, carers, advocates, care home staff and providers, and health and social care professionals.

You do not need to have experienced harm or made a complaint. We want to hear about everyday difficulties, near misses, examples of good practice and changes that have helped to make medication safer.

Email investigations@hssib.org.uk and briefly tell us:

• about your experience, role or organisation
• which of the three investigation areas you are contacting us about
• how you would prefer us to contact you.