Sample policy · Ambulance

Controlled drugs and vehicle medicines policy (ambulance)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). The real primary law for controlled drugs is the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001 and the Controlled Drugs (Supervision of Management and Use) Regulations 2013; the verbatim quotes below are from the engaged CQC Regulation 12, which carries the proper and safe management of medicines duty. · primary source

1. Who this ambulance medicines policy is for

This sample policy is for independent ambulance providers and patient transport services (PTS) that carry, store, check, administer, transfer or account for medicines on vehicles. It focuses on the evidence trail around controlled drugs, vehicle medicines, oxygen, emergency medicines, crew bags, base stock, patients' own medicines and handover at destination.

Use this page when the operational question is not just "do we have a medicines policy?", but "can we show how medicines and controlled drugs move safely between base, vehicle, crew, patient and destination?" That is the ambulance and PTS-specific intent. For a cross-sector starting point, use the CQC medication policy template. For the 2025 CQC controlled-drugs report angle, read CQC controlled drugs 2025: evidence for providers. For the wider ambulance evidence trail, use the ambulance and patient transport CQC compliance guide and the article on CQC compliance for ambulance and patient transport services.

This policy should sit alongside the service's crew clinical-scope policy, vehicle defect and roadworthiness policy, transfer-of-care policy, incident procedure, risk register and controlled-drug accountable-officer route where applicable.

2. What the regulation says

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

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))

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

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.

Patients' own controlled drugs are not service stock. Controlled drugs prescribed and supplied to an individual patient are not the same as service stock. The Service must not use a patient's own controlled drug for another patient, and must not hold stock controlled drugs unless it has the required legal authority and, where needed, Home Office licensing.

4. Purpose

This policy sets out how the Service orders, stores, carries, administers, records, checks and disposes of controlled drugs and other medicines carried on ambulance vehicles.

The Service must verify this policy against current Misuse of Drugs Act, Misuse of Drugs Regulations, Controlled Drugs Supervision of Management and Use Regulations, Home Office, CQC and NHS England controlled-drug source material before adoption.

5. Scope

This policy applies to:

This policy does not permit any medicine or controlled drug to be held, transported or administered unless the Service has the legal authority, governance approval, prescription, patient-specific direction or other lawful route required for that medicine.

6. Medicines governance framework

The Service keeps a medicines governance framework for every medicine and controlled drug it carries.

6.1 Approved medicines list

The Lead Clinician maintains an approved medicines list.

The list records:

Staff do not use an old printed list as authority to hold or use a medicine. The Lead Clinician verifies the list against current source material before approval and at review.

6.2 Ordering and receipt

The Service orders medicines only through approved suppliers and lawful routes.

The receipt record includes:

Controlled-drug receipt is recorded in the controlled-drug register where the current source material requires it.

6.3 Vehicle issue and return

The Service records medicines issued to each vehicle or crew bag.

The record includes:

Controlled-drug stock checks are completed at vehicle handover or shift handover according to the Service's current local procedure.

6.4 Storage and security

The Service stores medicines securely at the operating base and on vehicles.

The local procedure covers:

The Service checks whether a Home Office controlled-drugs licence is required before holding stock. The policy does not treat patients' own medicines and Service stock as the same category.

6.5 Vehicle and shift handover procedure

The Service completes the following procedure whenever medicines or controlled drugs move between base stock, a vehicle, a crew bag or an incoming and outgoing crew:

  1. Confirm authority: the receiving staff member confirms that the medicine is on the approved list and that their role, competency and local authority cover the handling duty.
  2. Check identity and condition: staff check the medicine, strength, quantity, expiry, seal and storage condition against the issue record.
  3. Reconcile the balance: the designated checker or checkers compare the physical stock with the controlled-drug register or vehicle stock record required by the local procedure.
  4. Record transfer of custody: the record identifies the vehicle or bag, outgoing and incoming staff, date, time, balance and any seal number used.
  5. Resolve exceptions before use: staff isolate damaged, expired, recalled or unexplained stock and escalate a mismatch immediately. They do not alter a balance to make the record agree.
  6. Confirm secure storage: the receiving crew places stock in the approved location and confirms that keys, codes and access controls are accounted for.
  7. Close the shift: the outgoing crew records administrations, breakages, returns and the final balance before custody is transferred or stock is returned to base.

Where an urgent patient-safety need interrupts the sequence, Staff provide care within their lawful authority and complete the reconciliation and incident record as soon as it is safe to do so. The Registered Manager reviews every unresolved discrepancy.

7. Administration, recording and patient medicines

Crew administer medicines only where the role, competency, legal route and clinical indication allow it.

The administration record includes:

Patients' own medicines travel with the patient only where the journey plan or referring service requires it. Crew record medicines handed over at destination and do not use a patient's own controlled drug for another patient.

8. Discrepancy, loss, theft, breakage and disposal

8.1 Controlled-drug discrepancy

If Staff identify a controlled-drug discrepancy, they record an incident immediately.

The Registered Manager and Lead Clinician:

The Service does not wait for the next audit to investigate a controlled-drug discrepancy.

8.2 Loss, theft or suspected diversion

If loss, theft or suspected diversion is identified, the Registered Manager escalates promptly.

The escalation record includes:

Where criminal activity may be involved, the Service considers police contact and preserves evidence.

8.3 Breakage, expiry and disposal

The Service records breakage, expiry and disposal according to the current source material and local procedure.

The record includes:

Staff do not restate controlled-drug disposal rules from memory. They check the current legal source and local accountable-officer route before disposal.

9. Responsibilities

10. Recording requirements

The Service keeps the following records:

Records are kept in the Service governance records and are available for internal review, CQC review, accountable-officer review, commissioner review and external review where required.

11. Audit cadence

The Service uses the following Verivius default audit rhythm unless current MDA, MDR, CDSMUR, Home Office, CQC, commissioner or local source material requires a different rhythm:

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

12. Version control and review date

The Service keeps a controlled copy of this policy. The footer or document-control table records:

13. Related records

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

14. 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.

15. 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.

16. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard, additively, preserving the original sections.
v1.1 2026-07-09 Verivius (sample) Clarified ambulance and PTS scope, internal links and the distinction from the cross-sector medicines template. No regulatory claims changed.
v1.2 2026-07-21 Verivius (sample) Added the vehicle and shift handover procedure from authority check through reconciliation and discrepancy escalation.

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.

Awaiting final verification

Whether your service's actual controlled-drug stock model requires a Home Office licence, which schedules the stock falls in, its safe-custody basis and its accountable-officer reporting route must be confirmed with a controlled-drugs pharmacist, accountable officer or Home Office licensing specialist.

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.

Controlled drugs on an ambulance pass through more changes of custody than almost anywhere else in healthcare: base to vehicle, vehicle to crew, crew to patient and on to the receiving unit, with the whole balance handed from an outgoing crew to an incoming one at every shift, and no dispensary, pharmacist or fixed cupboard in the picture. That is what makes diversion easy to hide here, because a missing dose can be lost in the gap between two vehicles, two bags and two shifts, and a patient's own controlled drug can quietly be absorbed into stock and given to someone it was never prescribed for. The record is not paperwork about a count that has already happened; it is the only thing that makes an unaccounted-for dose visible while there is still time to act. A register reconciled at each handover, safe custody that holds on a moving vehicle, and a loss escalated through the accountable officer, the police and CQC as separate duties are what protect two people at once: the patient who needs the medicine to be there, and the next patient who must never be given someone else's controlled drug. When it goes wrong the harm is rarely visible in the vehicle. It surfaces later, as a patient who did not get the relief the book said was on board, or as a shortfall no one can explain.

  1. Every controlled drug the Service holds as stock is entered in a controlled drugs register kept in the required form, so each receipt, administration, return and disposal traces to a running balance that is reconciled when custody changes hands, and a discrepancy is investigated at once, not left to the next audit, with its cause found rather than the figure adjusted so the book agrees.

    Strong evidence: The controlled-drug register (section 10) with dated receipt, issue, administration, return and disposal entries; the vehicle and shift handover reconciliation at procedure step 3 comparing physical stock against the register; and the discrepancy record at section 8.1 showing the last verified balance, the staff and vehicles involved and the cause identified before the next audit.

    Weak evidence: A register with gaps where administrations or end-of-shift returns were never entered, so the physical stock and the book can no longer be reconciled. Balances counted at base once a week but not at the point custody passes between crews, so no one can say which shift a shortfall belongs to. A discrepancy closed by writing in a corrected figure with no incident record, or an entry altered and overwritten rather than left as a fresh dated correction, so the register cannot show what actually happened. The register kept in the required form is the statutory duty here; the running balance and the reconciliation at each change of custody are the professional practice that makes an unaccounted-for dose visible.

    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.

    Regulations 19 and 20 of the Misuse of Drugs Regulations 2001 impose the controlled-drug register requirements for relevant Schedule 1 and Schedule 2 drugs where the provider is authorised to obtain or supply them. Confirm the schedules of the drugs actually held and the authority under which the service obtains and supplies them. Drugs outside Schedules 1 and 2 do not automatically attract the same statutory register requirement, but appropriate receipt, stock, administration, disposal and audit records may still be required under the Home Office licence, Regulation 12(2)(g), other provisions of the Misuse of Drugs Regulations and the service's controlled-drug procedures.

  2. The Service holds stock controlled drugs only where it has confirmed it is lawfully authorised to possess and supply them, with a Home Office licence where one is required, and a patient's own controlled drug travels back to that patient, never into another patient, so nothing is carried or given without the legal authority for it.

    Strong evidence: The approved medicines list (section 6.1) recording, for each controlled drug, its legal classification and the lawful route by which the Service may hold or administer it; the record at section 6.4 of whether a Home Office controlled-drugs licence is required before holding stock; and the section 7 administration record showing patients' own controlled drugs handed back at destination rather than reissued.

    Weak evidence: Stock controlled drugs carried because a supplier was willing to sell them, with nothing on file showing the Service checked its authority to possess or whether a Home Office licence was needed. An approved list that names the medicine but leaves the lawful-route and classification fields blank. A patient's own controlled drug logged as absorbed into vehicle stock, so the boundary between an individual's prescription and Service stock has quietly disappeared.

    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.

    An independent or private ambulance or patient-transport provider that holds service stock of controlled drugs and supplies that stock to healthcare professionals employed by the service normally requires a Home Office domestic controlled-drugs licence. The licence must cover the relevant drug schedules and the activities undertaken, including possession and supply. Patient-specific medicines and medicines transported solely on behalf of another lawful holder may follow a different route. Confirm the service's actual stock model and licence scope with the Home Office before any controlled-drug stock is obtained. The statutory framework is the Misuse of Drugs Act 1971 sections 4 and 5, the Misuse of Drugs Regulations 2001 and the conditions of the applicable Home Office licence.

  3. A controlled-drug loss, theft or suspected diversion is investigated at once and escalated through each route that applies in its own right. The service confirms whether its legal entity is a designated body that must appoint its own Controlled Drugs Accountable Officer, for example because it also operates an English independent hospital, or whether, as most independent ambulance and patient-transport providers are not, it reports controlled-drug incidents and concerns through the current regional NHS England Controlled Drugs Accountable Officer route instead. A police report where a crime may have occurred, a statutory notification to CQC where the threshold is met, a professional-regulator referral and a Disclosure and Barring Service referral are separate and conditional routes, and none is treated as having discharged the others.

    Strong evidence: The section 8.2 escalation record naming the substance, quantity, vehicle or location, the immediate safety action, external advice sought and the reporting decision; the section 8.1 requirement to preserve records, seals and vehicle storage and not wait for the next audit; and the quarterly governance review (section 11) of accountable-officer advice and external reporting decisions.

    Weak evidence: A suspected diversion handled internally and closed once the stock was replaced, with no evidence the controlled drugs accountable officer was told. A single line reading 'reported' with no note of which body received it, so it is impossible to tell whether the accountable officer, the police and CQC were each contacted or only one of them. A return-to-duty decision made about the staff member involved with no record of the reasoning or of any professional-regulator or Disclosure and Barring Service (DBS) referral considered.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  4. Controlled drugs are stored to a recognised safe-custody standard both at the operating base and on the vehicle, with access limited to authorised staff, keys and codes accounted for, and a documented response when a key is lost or a seal is broken, so stock is secure at every point it is not in a crew member's hands, not left in a glovebox or behind a shared-key drawer.

    Strong evidence: The storage and security procedure (section 6.4) covering who may access stock, key and code control, the vehicle storage location and arrangements when a vehicle is off base; the seal-number fields in the issue and handover records (sections 6.3 and 6.5); and the storage and security check in the recording requirements (section 10).

    Weak evidence: Controlled drugs kept in an unsecured compartment or a bag left in an unattended vehicle, with no record of who can reach the stock. Keys or codes shared across a base with no access list, so a loss could not be traced to anyone. A broken seal or a lost key noted verbally and replaced, with nothing showing the stock was reconciled and the risk assessed before the vehicle went back out. The proper and safe management of medicines is the statutory duty; the specific locked-safe standard and key and seal control are the recognised safe-custody practice the Service applies to meet it.

    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.

    The Misuse of Drugs (Safe Custody) Regulations 1973 Regulation 3 does not directly impose its premises-specific storage requirement on an ordinary independent ambulance station or an ambulance vehicle. The applicable legal duty is to ensure the proper and safe management of medicines under Regulation 12(1) and 12(2)(g). The detailed controls adopted by the service, including locked storage, restricted key access, vehicle seals, stock reconciliation and documented handover, should reflect its Home Office licence conditions, security guidance, risk assessment and controlled-drug procedures. Confirm whether any drug-specific or licence-specific storage condition applies to the actual stock held.

  5. A medicine or controlled drug is administered only where the crew member's role, registration and a lawful route actually cover it, and the administration is recorded in full, so a patient is treated by someone that medicine's authority reaches, not simply by whichever clinician happened to be on scene.

    Strong evidence: The approved medicines list (section 6.1) tying each medicine to the crew role authorised to administer it and the training and competency required; the section 7 administration record with patient identity, medicine, dose, route, time, clinical indication, the crew member administering and a second checker or witness where required; and the crew training and competency record (section 10).

    Weak evidence: An administration recorded against a crew member whose role or registration does not cover that medicine, with nothing on the approved list showing they were authorised for it. Administration entries missing the clinical indication or the second check where the local process requires one. A competency file that carries an old certificate but no current sign-off, so it cannot be shown the person was signed off to give what they gave.

    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. Expired, damaged or recalled medicines are segregated and taken out of use, medicines-safety alerts and recalls are acted on against the approved list, and the vehicle carries sufficient stock to meet need, so a recalled or out-of-date medicine is removed before it reaches a patient, not left in the bag until the next count finds it.

    Strong evidence: The expiry check and the segregation of expired, damaged or recalled stock (sections 6.4 and 10); the Service's own weekly review of expired stock and monthly review of medicine incidents (its default audit cadence, section 11); and the approved-list review against current Medicines and Healthcare products Regulatory Agency (MHRA) and CQC source material at section 6.1.

    Weak evidence: Expired or recalled stock still mixed with usable stock in a crew bag because segregation happens only when a shortage is noticed. A safety alert or recall that arrived but cannot be shown to have been checked against what the vehicles actually carry. An expiry check signed off as a routine tick with no record of what was found or removed, and no link from a recall notice to the batch that was pulled.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

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Last verified 20 July 2026

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Last reviewed 21 July 2026