Emergency Medicines and Equipment Checking Policy

1. What the regulation says

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

ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way, (Reg 12(2)(e) (equipment safety))

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))

Regulation 15 adds the premises-and-equipment duties this policy operationalises:

All premises and equipment used by the service provider must be ... clean, secure, suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. (Reg 15(1): the six criteria)

Regulation 17 adds the governance and audit duties:

Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Reg 17(1): the umbrella duty)

The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12, https://www.legislation.gov.uk/uksi/2014/2936/regulation/15 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/17. Where this policy and the regulation diverge, the regulation wins.

2. 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. Premises and equipment must also be clean, secure, suitable for purpose, properly used and maintained, and appropriately located (Regulation 15), and the service must run effective systems and processes, including audit, to assure quality and safety (Regulation 17). For emergency medicines and equipment this means the right items must be available, safe, in date, suitable for the service, checked regularly and ready for use.

3. Purpose

The purpose of this policy is to make sure that emergency medicines and equipment are available, safe, in date, suitable for the service, checked regularly and ready for use.

Emergency medicines and equipment are only useful if they work when needed. The service must have a reliable checking system, clear responsibility, trained staff and immediate action where anything is missing, expired, damaged or unsafe.

This policy supports Regulation 12 safe care and treatment, Regulation 15 premises and equipment, Regulation 17 good governance, Regulation 18 staffing and medicines safety requirements.

4. Policy warning

Emergency medicines or equipment must not be assumed safe because they are present on site.

If emergency medicines or equipment are missing, expired, inaccessible, damaged, uncharged, unclean, incomplete or unsuitable, the service must assess whether the affected activity can continue safely.

Where a required emergency medicine or item of equipment is unavailable, the Registered Manager or clinical lead must be informed immediately. The service may need to restrict, postpone or stop activity until safety is restored.

5. Scope

This policy applies to:

• emergency medicines
• anaphylaxis medicines
• oxygen
• defibrillators
• suction
• airway equipment
• emergency trolleys
• grab bags
• first aid kits
• blood glucose equipment
• procedure-specific emergency kits
• transport emergency kits
• home-visit emergency kits
• emergency call systems
• any other equipment required by service risk assessment

6. Principles

The service will make sure that emergency medicines and equipment are:

• identified through risk assessment
• suitable for the service provided
• available in sufficient quantity
• stored safely
• accessible in an emergency
• checked at defined intervals
• maintained and serviced where required
• used only by trained and authorised staff
• replaced after use, damage or expiry
• recorded and audited

7. Responsibilities

The Registered Manager is responsible for ensuring that this policy is implemented and audited.

The clinical lead, medicines lead or delegated competent person is responsible for advising what emergency medicines and equipment are required.

The named checker is responsible for completing checks on time and recording findings.

All staff are responsible for reporting missing, damaged, expired or unsafe emergency medicines or equipment immediately.

The provider is responsible for ensuring that resources are available to maintain emergency preparedness.

8. Emergency medicines and equipment list

The service must maintain a current list of required emergency medicines and equipment.

The list must state:

• item name
• required quantity
• location
• storage requirement
• expiry date where relevant
• servicing requirement where relevant
• checking frequency
• person responsible
• action if missing or unavailable

The list must be approved by a competent person and reviewed annually or sooner if the service changes.

9. Risk-based selection

Emergency medicines and equipment must be selected according to the service's actual risks.

The assessment must consider:

• treatments or procedures offered
• medicines administered
• age and needs of people using the service
• risk of anaphylaxis
• risk of sedation or local anaesthetic complication
• clinical complexity
• access to emergency services
• premises layout
• mobile working or transport
• staff competence
• professional guidance
• commissioner or contractual requirements

The service must not copy another service's emergency kit without checking whether it is suitable.

10. Checking frequency

The service must define checking frequency for each item.

As a minimum:

• emergency grab bags, emergency trolleys or procedure emergency kits must be checked at least weekly
• defibrillator status indicators must be checked at least weekly, or in line with manufacturer guidance if more frequent
• oxygen cylinders must be checked at least weekly and before planned higher-risk activity
• emergency medicines must be checked at least monthly for expiry, quantity and storage, and more often where local risk requires
• first aid kits must be checked at least monthly
• fridge-stored emergency medicines must be checked in line with the service's cold-chain procedure
• emergency equipment in vehicles or mobile kits must be checked before use or at a frequency justified by risk assessment

Checks must also be completed after use, after incident, after relocation, after maintenance, and after any concern that the kit may have been tampered with or compromised.

11. Check record

The check record must include:

• date and time
• location or kit checked
• items checked
• expiry dates where relevant
• quantity
• equipment condition
• battery or charge status where relevant
• oxygen cylinder level where relevant
• seal number where sealed kits are used
• fridge or storage temperature where relevant
• missing or damaged items
• action taken
• name and signature or electronic identity of checker
• escalation where required

A tick without evidence of what was checked is not enough for high-risk emergency kits.

12. Expiry management

The service must identify medicines and items approaching expiry before they expire.

The checking system must flag:

• expired medicines or equipment
• items expiring within the next [one / three] months
• items needing servicing
• items needing calibration
• items needing battery or pad replacement

Expired items must be removed from use immediately and replaced.

Where replacement is delayed, the Registered Manager or clinical lead must decide whether affected activity can continue safely.

13. Storage and access

Emergency medicines and equipment must be stored securely but be accessible quickly in an emergency.

Storage arrangements must consider:

• temperature
• light
• infection control
• tampering risk
• controlled-drug requirements where relevant
• access by authorised staff
• emergency access
• security during transport
• protection from damage
• clear labelling
• location known to staff

Staff must know where emergency equipment is kept.

14. Use of emergency medicines

Emergency medicines must only be administered by staff who are trained, competent and authorised to do so.

After administration, the record must include:

• medicine name
• dose
• route
• time
• reason
• person administering
• batch number where required
• expiry date where required
• response
• advice sought
• emergency services involvement
• replacement action

Use of emergency medicines must be reviewed as part of the incident record.

15. Controlled drugs

Where controlled drugs are included in emergency arrangements, the service must follow controlled-drug legislation and its Controlled Drugs Policy.

The service must maintain appropriate records for:

• receipt
• storage
• administration
• disposal
• balance checks
• discrepancies
• authorised access

Any discrepancy must be escalated immediately.

16. Equipment maintenance

Emergency equipment must be maintained in line with manufacturer guidance and service requirements.

The service must keep evidence of:

• servicing
• calibration
• electrical safety where applicable
• cleaning
• repair
• fault reporting
• replacement
• manufacturer alerts or recalls
• staff training

Faulty equipment must be removed from use and labelled clearly.

17. Cleaning and infection control

Reusable emergency equipment must be cleaned, decontaminated, stored and maintained in line with infection prevention and control requirements.

Single-use items must not be reused.

Used equipment must be replaced or decontaminated immediately after the event, according to manufacturer guidance and infection-control procedure.

18. Staff training and competence

Staff must receive training appropriate to their role on:

• where emergency medicines and equipment are kept
• how to call for help
• what they are authorised to use
• how to use relevant equipment
• emergency medicine limits and escalation
• checking procedures
• incident reporting after use
• replacement process after use

Training and competence must be recorded.

Staff must not be expected to use equipment or medicines outside their competence.

19. Missing, expired or faulty items

Where a check identifies a missing, expired, damaged or faulty item, the checker must:

• remove unsafe item from use where appropriate
• inform the Registered Manager or clinical lead immediately
• record the issue
• arrange replacement or repair
• assess whether any service activity must be restricted
• consider incident reporting
• consider risk register entry where replacement is delayed or repeated

The service must not continue higher-risk activity without required emergency cover.

20. After use

After emergency medicines or equipment are used, the service must:

• make sure the person is safe
• record the event
• replace medicines and consumables
• clean or decontaminate equipment
• reset or service equipment where required
• check the full kit
• record replacement
• review the incident
• identify learning or action

The kit must not be returned to service until it is safe and complete.

21. Audit

The Registered Manager must audit emergency medicines and equipment checks at least quarterly.

The audit must check:

• checks completed on time
• completeness of records
• expired items
• missing items
• repeated faults
• replacement delays
• servicing records
• staff training
• incident links
• action taken after gaps
• whether the emergency list remains suitable

Audit findings must be added to the action plan or risk register where required.

22. Related policies

This policy should be read with:

• Medical Emergencies and Deteriorating Patient Policy
• Safe Care and Treatment Policy
• Medicines Policy
• Controlled Drugs Policy
• Infection Prevention and Control Policy
• Equipment and Premises Policy
• Incident Reporting, Investigation and Learning Policy
• Risk Management and Risk Register Policy
• Training, Competency and Mandatory Training Policy
• Business Continuity and Emergency Preparedness Policy
• Record Keeping Policy

23. Review

This policy will be reviewed annually, or sooner following a medical emergency, emergency equipment failure, medicines incident, CQC finding, audit failure, service change, new treatment or procedure, or change in national guidance.

24. 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 15: Premises and equipment
• CQC Regulation 17: Good governance
• NICE medicines guidance
• MHRA safety alerts
• Resuscitation Council UK
• Manufacturer servicing guidance
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/12)

25. 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.

26. Document control

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