Sample policy · Adult social care

Care home medication policy template (adult social care)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 20 (duty of candour) and the Mental Capacity Act 2005 where covert administration arises. · primary source

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:

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

7. MAR chart standards

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

MAR records include:

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:

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:

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:

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:

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:

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:

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:

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:

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:

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:

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

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.

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

Version Date Author Changes
v0.1 2026-05-21 Verivius (sample) Initial sample template.
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard: added statutory anchor, verbatim Regulation 12 quotes, plain-English summary, standard Sources and further reading, When to seek further advice, and Document control. All original operational sections preserved and renumbered.
v1.1 2026-07-10 Verivius (sample) Added care-home and adult-social-care intent guidance, plus a clearer split from generic and domiciliary medicines pages. No regulatory claims changed.
v1.2 2026-07-19 Verivius (sample) Added named responsibilities, medicines reconciliation at transfers and a complete operational evidence set linked to the provider's governance registers.

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.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Medicines in a care home are handled round the clock, at volume, by staff who are usually not registered clinicians, for people who often cannot tell anyone that the tablet in the pot is the wrong one. That is what makes these records clinical rather than administrative. The medicine administration record (MAR), the as-required (PRN) protocol and the reconciliation note are frequently the only place where a new swallowing difficulty, a creeping increase in sedation, or a dose that quietly stopped after a hospital stay becomes visible to anybody. Two areas touch the person's rights and comfort most directly. Covert administration is a Mental Capacity Act 2005 decision about one specific medicine, informed by the prescriber and pharmacist and carrying a review date someone owns, not a standing arrangement inherited from the last shift. As-required medicines for pain or distress, given with no recorded reason and no recorded outcome, leave nobody able to say whether the person was helped or simply quietened. Controlled drugs carry a weight of their own, because a balance that has never been counted against the stock is an open question about whether someone at the end of life actually received the pain relief that was signed out for them.

  1. Every dose on the medicine administration record (MAR) is either signed as given or carries a coded reason for omission or refusal, not left as a blank box. An unexplained gap means nobody, including the colleague on the next round, can say whether the person had their medicine.

    Strong evidence: The MAR standards requiring an administration record, a reason for omission or refusal, and staff initials against a signature list (Section 7), with transcription only by trained and authorised staff, and the monthly audit checking MAR chart completeness, omissions and refusals (Section 16).

    Weak evidence: Blank boxes on the medicine administration record (MAR) that nobody has queried, a signature list so out of date that several sets of initials cannot be matched to a named worker, and omission codes used loosely so a refusal, a hospital appointment and a missing stock item all end up recorded the same way. The clearest tell is a monthly audit that records 'MAR charts checked, no issues' for a month where the charts plainly carry gaps, and no note anywhere of what was done about them.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 17(2)(c) (accurate, complete and contemporaneous record of the care and treatment provided and of decisions taken in relation to it), read with reg 12(2)(g) (proper and safe management of medicines)

  2. The controlled-drug register running balance reconciles with the stock physically held, and a discrepancy is escalated the moment it is found, not at the next audit. A balance that does not add up with no recorded action leaves nobody able to say whether a person's medicine reached them or went missing.

    Strong evidence: The controlled-drug register recording quantity received, administered, returned or disposed of, the running balance, the administering and witness signatures where two-person witnessing is required, and the reason for discrepancy and action taken, with any discrepancy escalated immediately to the senior person on duty and Registered Manager (Section 9). The monthly audit checks controlled-drug balances (Section 16).

    Weak evidence: Balances written up in the same hand and the same pen, day after day, with nothing to show that anyone counted the stock against the figure. A discrepancy dealt with by a crossing out or the bare word 'corrected' rather than a named person, a time, a reason and the action taken. Weak evidence also looks like the discrepancy first surfacing in the monthly audit rather than in a contemporaneous escalation to the senior person on duty and the Registered Manager, and a register kept for some controlled drugs but not others with nothing on file recording which stock the Service decided register controls apply to.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. Where medicine is given covertly, it rests on a recorded Mental Capacity Act 2005 process for that specific medicine decision, not on staff convenience. A medicine hidden in food with no capacity assessment, best-interest decision or prescriber and pharmacist involvement is being given to someone nobody has established is unable to make that decision.

    Strong evidence: The covert administration records made before it starts: the capacity assessment for the medicine decision, the best-interest decision, consultation with the prescriber, pharmacist and people interested in the person's welfare, why alternatives are not suitable, a review date and the MAR instruction (Section 11), with the policy stating covert administration is never used for staff convenience.

    Weak evidence: A MAR instruction reading 'give in yoghurt' with no capacity assessment behind it, or one capacity assessment done at admission treated as covering every medicine ever since. Thin evidence also looks like a best-interest record listing only staff views, with no advice from the prescriber or pharmacist on whether that particular preparation can safely be crushed or mixed, no record of why alternatives were judged unsuitable, and no review date, so the arrangement runs on unexamined.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 11(3) (where the service user lacks capacity, the provider must act in accordance with the Mental Capacity Act 2005); Mental Capacity Act 2005 s.2(1) (decision-specific capacity), s.4 (best interests) and s.4(7) (consultation)

  4. When a medication error or near miss happens, it is handled as an incident: the person is made safe, the record preserved and openness with the person considered, not quietly corrected. What goes wrong is an error with no incident record, no contact with the person or their family, and no separate consideration of two distinct duties: the Regulation 20 duty of candour owed to the person, whose notifiable safety incident threshold for a registered person that is not a health service body sits under Regulation 20(9), and a statutory notification to CQC, which is a separate duty and is not discharged by being open with the person.

    Strong evidence: The error steps to make the person safe, seek clinical advice, preserve the MAR chart and medicine evidence, inform family or representative according to consent and duty of candour, and consider separately a safeguarding referral to the local authority, a statutory notification to CQC and the Regulation 20 duty of candour owed to the person, none of which discharges either of the others (Section 14), with the Registered Manager reviewing medication incident themes at least monthly.

    Weak evidence: An error that survives only as a line in the daily notes or the handover book, with the MAR chart rewritten cleanly and the original discarded, so nobody can see what was first recorded. Weak evidence also looks like an incident form where 'safeguarding' and 'duty of candour' are marked not applicable with no reasoning, leaving nothing to show that anyone weighed the harm against the Regulation 20 notifiable safety incident threshold that applies to a registered person other than a health service body, considered a safeguarding referral to the local authority as a separate question, or considered whether a statutory notification to CQC was due as a third.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 20 (duty of candour: reg 20(1) openness, reg 20(2)-(3) notification and apology, reg 20(8)-(9) notifiable safety incident thresholds), with reg 12(2)(b) (mitigating risks to health and safety) and Care Quality Commission (Registration) Regulations 2009, reg 18 (notification of other incidents)

  5. Medicines are reconciled each time the person moves (admission, return from hospital, transfer, discharge), not carried over on trust. Where a discharge change is missed, the person carries on with an old or wrong regimen and the staff giving it have no way of knowing.

    Strong evidence: Reconciliation of the current prescription or discharge information against medicines supplied, the MAR and known allergies at admission, return from hospital, transfer and discharge, with discrepancies resolved with the prescriber or pharmacy before the next dose where safe, and a handover recording medicines sent, latest administration time, omitted or refused doses, as-required (PRN) use, monitoring due and controlled drugs (Section 8).

    Weak evidence: A person comes back from hospital and the old MAR simply continues, with the discharge letter filed unread in the back of the care file and no record of anyone comparing it against the medicines actually in the trolley. Weak evidence also looks like a transfer handover that says 'medicines sent with resident' and no more: no last administration time, no omitted or refused doses, no as-required (PRN) use, no allergy check and no note of who would act on a change.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  6. Each as-required (PRN) medicine has a person-specific protocol, and staff record why they gave it and what happened, not just that a dose went out. A PRN sedative or painkiller given routinely with no indication, maximum dose or recorded outcome leaves nobody able to say whether the person's pain or distress was relieved, or whether sedation has drifted into routine.

    Strong evidence: The person-specific PRN protocol recording what the medicine is for, the signs that indicate use, the dose and maximum dose and minimum interval from the prescription, and how effect is reviewed, with staff recording the reason for giving PRN medicine and the outcome (Section 12). The monthly audit checks PRN records (Section 16).

    Weak evidence: An as-required (PRN) protocol that is little more than a copy of the prescription label, naming the dose but not what the medicine is for, what the person looks like when they need it, or what to try before reaching for it. On the chart the doses are initialled at much the same time every day with no reason and no outcome, so a sedative or a painkiller drifts into routine use and nobody can say whether the person's pain or distress was relieved or even reassessed.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

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Last verified 20 July 2026

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Last reviewed 19 July 2026