Sample policy · Reg 12

Emergency Medicines and Equipment Checking Policy

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 15 (premises and equipment) and Regulation 17 (good governance). · primary source

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Verivius pack version v1.1, 2026-07-19

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:

5.1 Local arrangements before adoption

Before adoption, the provider records and displays where staff need it:

The provider must test that staff can find the correct kit, call for help, identify what they are authorised to use and restore the kit after use. A generic list copied from another service is not a local emergency arrangement.

6. Principles

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

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:

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:

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

10. Operational checking workflow and frequency

The named checker follows this sequence for every scheduled or post-use check:

  1. Open the approved list: confirm the correct location, kit or vehicle and use the current item list rather than relying on memory.
  2. Inspect every control: verify identity, quantity, expiry, seal, condition, charge, cylinder level, storage and servicing status as applicable. Check that staff can reach the equipment without delay.
  3. Record the result: enter the date, time, item-level result, checker identity and any action in the approved check record. Do not pre-sign or retrospectively complete a check that was not done.
  4. Remove unsafe items: quarantine expired, damaged, contaminated, recalled or faulty stock so it cannot be selected in an emergency. Preserve controlled-drug and medicines records where applicable.
  5. Escalate the gap: notify the clinical lead or Registered Manager immediately, assess whether activity can continue safely and record any restriction, alternative cover or service interruption.
  6. Replace and recheck: obtain the authorised replacement or repair, inspect it against the approved list and update stock, servicing and expiry records.
  7. Restore and review: a competent person confirms the kit is complete and ready before it returns to service. Record an incident, risk or improvement action where the gap was high risk, repeated or revealed a failed system.

The service must define checking frequency for each item and increase it where manufacturer instructions, professional guidance, treatment risk, use or local experience require this.

As a minimum:

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:

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 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:

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:

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:

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:

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:

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:

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:

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:

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

22. Related policies

This policy should be read with:

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.

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

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.
v1.1 2026-07-19 Verivius (sample) Added local kit and accountability decisions plus an end-to-end check, quarantine, escalation, replacement and restoration workflow.

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.

Emergency medicines and equipment are the one part of a service that is meant never to be used, and that is exactly why they fail quietly. A drug given every day announces its own problems, but a resuscitation trolley, an oxygen cylinder, a defibrillator or an anaphylaxis kit gives no feedback at all between the day it was stocked and the day someone collapses in front of it. By then it is too late to learn that the adrenaline expired last month, the battery is flat, the cylinder is empty, or the airway that should be in the drawer was borrowed and never replaced. Nothing in the ordinary run of the day will surface any of that, so the check record is not paperwork sitting alongside the real safeguard: it is the safeguard, the single mechanism that forces someone to open the box on a schedule and prove, item by item, that it will work. That is why 'present on site' is never the test and a sealed lid is never reassurance. When the trail is honest, the person who collapses in the waiting room, the treatment chair, the ambulance or their own front room meets a kit that is genuinely ready and staff who know what they are allowed to reach for. When it is a wall of identical ticks, the first anyone learns of the gap is the emergency itself, which is the worst possible moment to find out.

  1. The emergency medicines and equipment a person needs are genuinely there, in date, complete and reachable at the moment someone collapses, not merely stored on site: the failure that matters is a sealed, tidy-looking trolley that turns out to be missing an airway, holding an expired adrenaline ampoule, or standing behind a door nobody on shift can open.

    Strong evidence: The completed emergency check record for each kit, trolley, vehicle and grab bag, worked against the current approved item list and showing item-level results: expiry dates, quantities, seal integrity, defibrillator charge, oxygen cylinder level and that the equipment can be reached without delay (sections 10 and 11), rather than a column of ticks.

    Weak evidence: A month of identical ticks in one pen, including ticks on days the service was closed, with no column for what was actually found: no expiry written down, nothing on the defibrillator pad or battery, no cylinder level. Weakest of all is a complete-looking sealed trolley on the day of the visit that nobody can say who last opened, or when. The check frequency the service sets is a recommended cadence; what is not optional is that the items are genuinely in date, sufficient and reachable.

    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 12(2)(e), (f) and (g)

  2. The emergency list is built from this service's own risks and signed off by a competent person, not copied from another service: a clinic that injects, sedates or gives local anaesthetic can point to the anaphylaxis provision that decision requires, rather than a generic kit that lists items it never uses and misses the ones its own procedures make foreseeable.

    Strong evidence: The approved emergency medicines and equipment list for each location, treatment area, vehicle and home-visit kit, recording the competent person who approved it, the source guidance checked (for example the Resuscitation Council UK recommended equipment and drug lists) and the date of the next suitability review (sections 5.1, 8 and 9).

    Weak evidence: One list photocopied from a neighbouring practice with no named approver and no review date, naming risks the service does not run while omitting the ones it does. The tell is a list that has never changed even though the service has since added a new procedure, a transport route or a treatment that carries its own emergency risk.

    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. When a check finds something missing, expired, damaged or faulty, it is taken out of reach so it cannot be grabbed in an emergency, and the gap is escalated immediately to someone empowered to restrict, postpone or stop the affected activity until safety is restored: activity that depends on emergency cover does not quietly continue while the cover is gone.

    Strong evidence: The quarantine and escalation trail for a real gap: the unsafe item removed and held apart from live stock, the clinical lead or Registered Manager informed, the recorded decision on whether activity could continue safely, and the recheck and competent-person sign-off before the kit returned to service (sections 10, 19 and 20).

    Weak evidence: An expired ampoule or a flat defibrillator battery still sitting in the kit weeks after a check noted it, so the next person reaches for the very item the record already flagged. Or a gap logged with no evidence anyone was told, no decision on whether the session should have gone ahead, and the kit back in use with nobody confirming it was complete.

    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. Expiry, servicing, calibration, battery and defibrillator-pad dates are tracked and flagged before they lapse, not discovered after the fact: the service knows an item is approaching its limit while there is still time to replace it, rather than finding a dead battery or an out-of-date pad at the one moment the device is needed.

    Strong evidence: The expiry and maintenance register that flags medicines and consumables approaching expiry and equipment due for service, calibration, battery or pad replacement ahead of time, held with the retained servicing, calibration, electrical-safety and manufacturer alert or recall records for each item, each worked to the manufacturer's stated schedule (sections 12 and 16).

    Weak evidence: A defibrillator whose pad and battery expiry is recorded nowhere because 'the device self-tests', service dates already lapsed with no next-due date entered, or expiry noticed only after the item had already passed it. No interval or cycle figure belongs in the check; what belongs there is proof the service follows and records the manufacturer's own schedule.

    The instructions from the maker of a product, device, or medicine. Following them is how the item is used safely, and for medical devices it is effectively expected.

  5. Where controlled drugs are held, the service records receipt, use, disposal and stock discrepancies in accordance with the requirements applicable to the drug's schedule and its own medicines procedures. A running balance and immediate discrepancy escalation are service controls unless a statutory register requirement applies to the particular drug.

    Strong evidence: The controlled-drugs receipt, storage, administration, disposal and stock-reconciliation records for the emergency stock, held to safe-custody storage for the controlled drugs that require it, reconciled to the physical count, with discrepancies escalated and handled under the service's Controlled Drugs Policy (section 15).

    Weak evidence: An emergency controlled drug logged only when it was put in and never counted again, a running balance written up later rather than at the point of access, or a discrepancy noted with no escalation. Storing an emergency controlled drug loose in the trolley for speed, with no record of who could reach it, is the version that reads as convenient until it is questioned. Safe-custody storage is the statutory part for a controlled drug that requires it. The running-balance reconciliation is recognised professional practice. A statutory controlled-drugs register is required for a Schedule 2 drug but not for a Schedule 3 emergency drug such as midazolam, which needs safe custody without a statutory register.

    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. A named lead audits the whole checking system on a defined cycle and re-tests whether the emergency list is still the right one, so missed checks, repeated faults, replacement delays and training gaps become tracked actions rather than a pattern nobody owns: the audit asks whether the kit would actually work, not just whether the sheets were signed.

    Strong evidence: The periodic emergency-preparedness audit covering checks completed on time, record completeness, expired or missing items, repeated faults, replacement delays, servicing and training currency and whether the list remains suitable, with findings carried to the action plan or risk register (section 21).

    Weak evidence: An audit that counts signed check sheets and stops there, never opening a kit to test whether it is complete, and never reconciled against the incidents where a check was missed or an item was found out of date. The audit cadence is a recommended default; the duty to run effective systems that monitor and improve the safety of care is the statutory part behind it (Regulation 17).

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  7. Where Schedule 2 controlled drugs are held, the statutory register requirements under Regulations 19 and 20 of the Misuse of Drugs Regulations 2001 are followed. A midazolam or other Schedule 3 medicine is not presented as requiring a statutory controlled-drug register or a Safe Custody Regulations cabinet: running-balance and discrepancy handling for those are the service's own controls unless a statutory register requirement applies to the particular drug.

    Strong evidence: The controlled-drugs register for any Schedule 2 stock, and the medicines procedure showing the recording controls applied to each drug by its schedule.

    Weak evidence: A single controlled-drug register or safe treated as universal, applied to a Schedule 3 emergency drug such as midazolam that does not attract the statutory register, or Schedule 2 stock with no statutory register at all.

    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.

    Misuse of Drugs Regulations 2001, regs 19 and 20 (statutory controlled-drug register, principally Schedule 1 and 2). Midazolam (Schedule 3) is exempt from the Safe Custody Regulations storage requirement and does not attract the statutory register.

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Last verified 23 July 2026

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Last reviewed 19 July 2026