Care home medication policy template (adult social care)

1. Who this care home medication policy is for

This sample policy is for adult social care providers that administer, prompt, store, record, audit or dispose of medicines for people in care homes, nursing homes, supported living or residential services. It is written for providers that need a care home medication policy or adult social care medication management policy, not just a generic medicines procedure.

Use this page when the evidence question is: can we show safe medicines practice in day-to-day care? It covers MAR chart standards, controlled drugs, PRN medicines, refusals, covert administration under the Mental Capacity Act, storage, disposal, medication errors, staff competency and audit.

For a cross-sector starting point, use the CQC medication policy template. For community-based medication support, use the domiciliary care medicines support policy. For audit evidence, use the care home medicines audit checklist.

2. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

the proper and safe management of medicines, (Reg 12(2)(g) (medicines management))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

where equipment or medicines are supplied by the service provider, ensuring that there are sufficient quantities of these to ensure the safety of service users and to meet their needs, (Reg 12(2)(f) (sufficient equipment + medicines supply))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

3. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations.

4. Purpose

This policy sets out how the Service manages medicines safely, including administration, storage, transport, disposal, records, refusals, covert administration, PRN medicines, errors and learning.

The Service must verify this policy against NICE social-care medicines guidance, CQC medicines guidance, medicines legislation, controlled-drug requirements and local pharmacy procedures before adoption.

This is the adult social care and care-home version. For a cross-sector starting point, use the CQC medication policy template. For an inspection-ready audit tool, use the care home medicines audit checklist.

5. Scope

This policy applies to:

• medicines administration
• medicines support and prompting
• ordering and receipt
• storage and security
• transport between settings
• disposal and returns
• MAR chart records
• controlled drugs
• PRN medicines
• refused medicines
• covert administration
• medication errors and near misses

It applies to prescribed medicines, non-prescription medicines, homely remedies where used, topical preparations, nutritional supplements and controlled drugs.

Before adoption, the provider identifies its pharmacy and prescriber contacts, medicines-ordering cycle, out-of-hours clinical route, authorised roles, storage locations, records systems and transfer-handover process. Supported-living services must remove any care-home controls they do not operate and document the responsibilities they have accepted.

6. Roles and responsibilities

• Provider or Nominated Individual: ensures the service has safe medicines systems, competent staffing, suitable storage and enough resources to act on incidents and audit findings.
• Registered Manager: approves the local procedure, assigns authorised roles, oversees incidents and discrepancies, and confirms that medicines risks and improvement actions are closed.
• Medicines lead or senior person on duty: coordinates ordering, receipt, reconciliation, stock checks, controlled-drug checks, temperature escalation and day-to-day advice.
• Staff administering or supporting medicines: work only within assessed competence, check the current MAR and person-specific instructions, record immediately, and escalate omissions, refusals, discrepancies or deterioration.
• Staff arranging orders or receipt: order against current prescriptions and stock, check deliveries, record quantities and discrepancies, and avoid avoidable over-ordering.
• Prescriber and pharmacy interface: the named service role seeks medicine-specific advice, supplies accurate records for review or transfer, and confirms who will act on changes.

7. MAR chart standards

The Service keeps a current medicine administration record for each person receiving medicines support.

MAR records include:

• person's name and date of birth
• medicine name, strength, form and route
• dose and timing
• start date and stop date where relevant
• allergies and sensitivities
• prescriber or pharmacy source where relevant
• administration record
• reason for omission or refusal
• staff initials and signature list
• PRN protocol reference where relevant
• topical body-map reference where relevant

Staff do not transcribe medicines unless they are trained and authorised under the Service procedure. Any handwritten or amended entry is checked according to current NICE social-care medicines guidance and local pharmacy process.

8. Administration, storage, transport and disposal

Medicines are administered only by staff who are trained, competent and authorised for that task.

The Service:

• stores medicines securely and according to the medicine instructions
• records fridge temperatures where medicines require cold storage
• keeps medicines separate for each person where required
• transports medicines securely when people move between settings
• records medicines received and returned
• disposes of medicines through the approved pharmacy or waste route
• keeps records of disposal and returns

The Service verifies storage, transport and disposal detail against NICE social-care medicines guidance, CQC medicines guidance and pharmacy advice before adoption.

At admission, return from hospital, transfer between settings and discharge, the authorised worker reconciles the current prescription or discharge information against medicines supplied, the MAR and known allergies. Discrepancies are resolved with the prescriber or pharmacy before the next dose where safe to do so. The handover records the medicines sent, the latest administration time, omitted or refused doses, PRN use, monitoring due, controlled drugs and any urgent follow-up.

9. Controlled-drug register

Where the Service holds controlled drugs requiring register controls, the Service keeps a controlled-drug register.

The register records:

• date and time
• person using the service
• medicine name, strength and form
• quantity received, administered, returned or disposed of
• running balance
• signature of staff member administering or checking
• witness signature where the current procedure requires two-person witnessing
• reason for discrepancy and action taken

The Registered Manager sets the reconciliation cadence from current controlled-drug legislation, NICE social-care medicines guidance, pharmacy advice and local procedure. This template does not restate controlled-drug legal intervals.

Any discrepancy is escalated immediately to the senior person on duty and Registered Manager.

10. Refusal of medication

A person can refuse medicine if they have capacity for that decision.

When a person refuses medicine, staff:

• offer information and support in a way the person can understand
• do not force or hide the medicine
• record the refusal on the MAR chart
• record the reason where the person gives one
• follow the PRN or prescribed medicine protocol where relevant
• inform senior staff where refusal creates risk
• seek prescriber or pharmacist advice where repeated refusal or high-risk medicine is involved
• review capacity where there is reason to doubt capacity for the decision

Refusal patterns are reviewed through care-plan review and medicines audit.

11. Covert administration MCA pathway

Covert administration is used only where the person lacks capacity for the specific medicine decision and the process is lawful, necessary and in the person's best interests.

Before covert administration starts, the Service records:

• capacity assessment for the medicine decision
• best-interest decision
• consultation with the prescriber, pharmacist and people interested in the person's welfare
• why alternatives are not suitable
• medicine-specific administration advice
• review date
• care-plan wording
• MAR chart instruction

Covert administration is never used for staff convenience. The capacity assessment and best-interest decision are made under the Mental Capacity Act 2005 and its Code of Practice (2007, update in consultation); these requirements are unchanged. The Service verifies the process against the Mental Capacity Act 2005, NICE social-care medicines guidance and CQC medicines guidance before adoption.

12. PRN protocols

Each PRN medicine has a person-specific protocol.

The protocol records:

• what the medicine is for
• signs or symptoms that indicate use
• dose and maximum dose according to the prescription
• minimum interval according to the prescription
• non-medicine approaches to try where appropriate
• when to seek senior or clinical advice
• how effect is reviewed and recorded
• when the protocol is reviewed

Staff record the reason for giving PRN medicine and the outcome.

13. Medication review with prescribers

The Service supports regular medication review with prescribers, pharmacists and relevant healthcare professionals.

Review is considered:

• after admission or start of support
• after hospital discharge
• after medicine change
• after falls, sedation, swallowing concern or weight change
• after repeated refusal
• after medication error
• when the person, family, staff or prescriber raises concern
• at planned care review

The Service does not set clinical review intervals from this template. Staff check NICE social-care medicines guidance, prescriber advice and local medicines pathway.

14. Medication errors and learning

Medication errors and near misses are recorded as incidents.

Staff:

• make the person safe
• seek clinical advice where needed
• inform senior staff and the Registered Manager
• record what happened
• preserve MAR chart and medicine evidence
• inform family or representative according to consent and duty of candour requirements
• consider safeguarding, CQC notification and Regulation 20 duty of candour
• assign corrective actions

The Registered Manager reviews medication incident themes at least monthly.

15. Staff competency assessment

Staff administer medicines only after training and competency assessment.

Competency covers:

• medicines policy and procedure
• MAR chart use
• infection prevention during administration
• medicines storage
• controlled-drug process where relevant
• PRN protocols
• refusal
• covert administration escalation
• error reporting
• person-centred communication

Competency is reassessed after concern, incident, long absence or procedure change.

16. Audit cadence

The Registered Manager audits medicines practice at least monthly.

The audit includes:

• MAR chart completeness
• omissions and refusals
• PRN records
• controlled-drug balances where relevant
• storage and temperature records
• disposal and returns
• medicine errors and near misses
• covert administration records
• staff competency records
• medication-review actions

Audit findings are recorded as improvement actions with an owner and review date.

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

17. Records and evidence

The medicines record must show what was expected, what happened, who acted and what follow-up remains. Each applicable item must be recorded in the named operational or governance record:

• current prescriptions, MAR charts and specimen signature records
• medicines ordered, received, carried forward, returned and disposed of
• admission, hospital-return, transfer and discharge reconciliation records
• controlled-drug register entries, balances, checks and discrepancy actions
• fridge and room-temperature logs, excursions and product-disposition decisions
• person-specific PRN protocols, covert-administration decisions and body maps
• refusals, omissions, errors, near misses, clinical advice, duty-of-candour decisions and incident references
• medication-review requests, outcomes, monitoring and care-plan changes
• staff training, observed competency, reassessment and authorisation records
• audit results, trend reviews, risk controls and improvement actions

Records are made as soon as possible after the activity and are cross-linked to the person's care record, incident register, audit register, training matrix, risk register and improvement-actions register where applicable. Access, retention and disposal follow the provider's information-governance procedure.

18. Related reading

• Cross-sector policy: CQC medication policy template
• Community medicines support: Domiciliary care medicines support policy
• Audit checklist: Care home medicines audit checklist
• Sector hub: Adult social care guide

19. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• CQC Regulation 12: Safe care and treatment
• CQC Regulation 20: Duty of candour
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/20)
• NICE SC1, Managing medicines in care homes (https://www.nice.org.uk/guidance/sc1)
• NICE NG67, Managing medicines for adults receiving social care in the community
• CQC medicines optimisation guidance and MAR record expectations
• MHRA safety alerts
• Misuse of Drugs Regulations 2001 (https://www.legislation.gov.uk/uksi/2001/3998/contents)
• Controlled Drugs (Supervision of Management and Use) Regulations 2013 (https://www.legislation.gov.uk/uksi/2013/373/contents)
• NHS England controlled drugs accountable officer guidance where applicable
• Mental Capacity Act 2005 (https://www.legislation.gov.uk/ukpga/2005/9/contents) and MCA Code of Practice (2007, update in consultation), for covert administration capacity and best-interest decisions

20. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

21. Document control

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.