Sample policy · Medicines

CQC medication policy template

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 the Human Medicines Regulations 2012 (SI 2012/1916), the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001 (SI 2001/3998), the Misuse of Drugs (Safe Custody) Regulations 1973, and the Controlled Drugs (Supervision of Management and Use) Regulations 2013 (SI 2013/373). · primary source

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Verivius pack version v1, 2026-06-10

1. 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.

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. Regulation 12 is central to CQC's safety expectations.

The proper and safe management of medicines under Regulation 12 is delivered through two parallel statutory tracks. The general medicines framework is in the Human Medicines Regulations 2012, which classifies medicines (Prescription-Only, Pharmacy, General Sale), specifies who can prescribe, supply and administer them, and sets record-keeping requirements. The controlled drugs framework is in the Misuse of Drugs Act 1971 plus the Misuse of Drugs Regulations 2001 (which set the Schedule 1 to 5 classifications, register, safe custody and destruction requirements) plus the Controlled Drugs (Supervision of Management and Use) Regulations 2013 (which establish the Accountable Officer role, mandatory standard operating procedures, and Local Intelligence Network participation). For independent secondary care, the load-bearing operational requirements are: a named Accountable Officer for Controlled Drugs (CDAO), current standard operating procedures covering prescribing, supply, administration and clinical monitoring, a properly maintained CD register, safe custody compliant with the Misuse of Drugs (Safe Custody) Regulations 1973, and witnessed destruction of CDs by an Authorised Witness who is not the Accountable Officer.

This page is the cross-sector starting point. If you run a care home, a domiciliary service, or a GP practice, use the sector-specific policy or audit pages linked near the end of this template.

3. Scope

This policy applies to all staff at who prescribe, supply, administer, store, transport, or dispose of medicines or controlled drugs, plus the Accountable Officer for Controlled Drugs (CDAO) where the role exists. It covers prescription-only medicines, pharmacy medicines, general-sale medicines, every Misuse of Drugs Schedule 1 to 5 controlled drug stocked or handled at any site, the CD register, the CD safe and any other safe-custody location, and the standard operating procedures (SOPs) covering prescribing, supply, administration, and clinical monitoring.

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4. Roles and responsibilities

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5. Procedure

The medicines management procedure operationalises the prescribing-supply-administration-disposal chain.

  1. Prescribing. Prescribers prescribe within their professional scope, per the local formulary, and in line with relevant NICE guidance (for example NG5 on medicines optimisation, and NG67 on managing medicines for adults receiving social care in the community where it applies), with indication, dose, frequency, duration, and review point recorded. Electronic prescribing is used where available; paper prescriptions follow the legal-format requirements of the Human Medicines Regulations 2012.
  2. Supply and stock. Medicines are obtained from authorised wholesalers or pharmacies. Stock is held within the licensed conditions (temperature-monitored where required for cold-chain). Stock checks against the medicines register run weekly; near-expiry stock is flagged and used or disposed of per the disposal procedure.
  3. Controlled drugs storage. CDs in Schedules 2 and 3 (where they require safe custody under the Misuse of Drugs (Safe Custody) Regulations 1973) are held in a compliant CD cabinet (BS 2881 spec). The CD cabinet is in a defined location, locked, with key control limiting access to authorised staff.
  4. Controlled drugs register. Every receipt, supply, administration, and disposal of a Schedule 1 or 2 CD is recorded in the CD register at the time of the action. The register entries include date, name and quantity, person to whom supplied or by whom administered, the receiver or witness, balance running total. The register is bound and rules-line ruled; electronic CD registers are accepted only where they meet the Home Office requirements.
  5. Administration. Administration follows the local SOP and the relevant clinical guideline. The Five Rights (right patient, right drug, right dose, right route, right time) are checked at the point of administration. Documented immediately; administration record forms part of the clinical record.
  6. CD destruction. CDs that need to be destroyed (expired, contaminated, returned by patient) are destroyed in the presence of an Authorised Witness who is not the CDAO. The destruction is recorded in the CD register and on the destruction log.
  7. Incident reporting. Any medicines-related incident, including an error in prescribing, supply or administration, a missed or omitted dose, and a medicine the person refused, is logged the same shift through the incident reporting policy. The service checks whether the person came to harm and gets medical help where needed. The Reg 18 (Registration Regulations 2009) notification check runs at log-time; serious medicines incidents may meet the trigger. Medicines incidents are reviewed together to find patterns, not treated as a single worker's fault.
  8. Patient self-administration (where applicable). Where the service supports patient self-administration, a self-administration risk assessment is recorded, the medication is held in a patient-specific lockable cabinet, and the self-administration record runs alongside the clinical record.
  9. Medicines reconciliation. At every patient transition (admission, transfer, discharge), the medicines list is reconciled against the prescribing record and any changes are documented. Reconciliation is a clinical step, not an administrative one.
  10. Quarterly audit and pattern review. The Medicines Management Lead or CDAO runs the audit per the audit section below and presents at the monthly clinical governance committee.

6. Assessing medication needs, consent and the level of support

Before the service supports a person with medicines, it assesses what support they need and secures consent:

7. Specific administration situations

The service has clear arrangements for situations that carry extra risk:

8. Training and competency

Training records held in the tenant's training matrix register.

9. Audit

Compliance with this policy is monitored by the Medicines Management Lead or CDAO:

Audit findings recorded in the tenant's audit register; actions logged in the improvement-actions register.

10. Record-keeping

Medicines records (prescribing, supply, administration, reconciliation) form part of the clinical record and are held for a minimum of 8 years from the date of the last entry per the NHS Code of Practice on Records Management.

Controlled drugs registers are held for a minimum of 2 years from the date of the last entry per the Misuse of Drugs Regulations 2001, regulation 19(1)(a). Most providers retain CD registers for 7 years aligned to clinical-record retention.

Patient-specific medication charts, destruction logs, and any incident records arising from medicines are retained per the source-record retention.

Verivius preserves the per-record audit trail indefinitely while the workspace is active.

11. Sector-specific medicines pages and related policies

12. 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.

13. 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.

14. Document control

Version Date Author Changes
v1 2026-05-19 Verivius (sample) Initial sample template.
v1.1 2026-06-01 Verivius (sample) Filled out Sections 3 to 8 with concrete content. Section 4 names the CDAO, Authorised Witness, and Medicines Management Lead roles. Section 5 expanded to a 10-step procedure covering prescribing, supply, CD storage, CD register, administration, CD destruction, incident reporting, self-administration, reconciliation, audit. Section 6 names training tiers. Section 7 names the four audit cadences. Section 8 references the NHS Code of Practice and the Misuse of Drugs Regulations 2001 reg 19(1)(a) CD-register minimum.
v1.2 2026-06-05 Verivius (sample) CQC content-checklist pass. The policy was strong on controlled drugs and clinical administration but missing CQC's social-care medicines dimensions. Added Section 6 (assessing medication needs, MCA consent, the prompting/assisting/administering levels of support, and home-storage agreements for care in people's own homes) and Section 7 (covert administration, PRN protocols, sharps and injectables, medical gases, delegated healthcare tasks, MAR governance, and STOMP/STAMP for learning disability and autism). Added NICE alignment (NG5, NG67) to prescribing, omissions and refusals to incident reporting, and a competency-assessment requirement to training. Sections renumbered; updated stale related slugs.
v1 2026-06-10 Verivius (sample) Re-conformed to the current Verivius policy standard, preserving the original content. Anchored the verbatim "What the regulation says" block to Regulation 12 (safe care and treatment) while retaining the Human Medicines and Misuse of Drugs framework in the anchor line and sources. Added the Plain-English summary, Sources and further reading, and When to seek further advice sections, and refreshed the disclaimer and footer to the current house wording. All original sections and rules preserved.

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.

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 are the one area of care where a single quiet slip changes a person's health or their independence before anyone notices: a dose given twice, a controlled drug that never reaches the person it was signed out for, or an inhaler taken over from someone who could still manage it themselves. The controlled-drugs running balance is usually the only real-time signal that a Schedule 2 drug has gone astray, so a balance written up later or never counted against the cabinet is not a paperwork lapse but the loss of the earliest warning of theft or a dosing error. Covert administration and the choice between prompting, assisting and administering sit at the sharp edge of a person's autonomy, where getting the capacity and consent trail wrong either strips a right the person still held or puts a crushed medicine into food in a way that can change how the drug works. The same is true of psychotropic medicines prescribed to people with a learning disability or autism, where nobody revisiting the prescription is itself the harm. Contemporaneous registers, administration records that carry a reason for every missed dose, and a recorded best-interests decision are what let a service catch its own near-misses and show a person and their family that their medicines were handled with the same care as their diagnosis. A well-led service reads a medicines incident as a system to fix rather than a worker to blame, because the same gap will otherwise reach the next person.

  1. The controlled-drugs register running balance reconciles to the physical stock in the cabinet, with every receipt, supply, administration and disposal entered at the time of the action and any discrepancy investigated the same shift, not a register written up later or a balance that does not match.

    Strong evidence: The controlled-drugs register (date, name and quantity, person supplied or administering, receiver or witness, running balance), the weekly stock check reconciling each controlled-drugs cabinet balance to the register with same-shift investigation of discrepancies, and the quarterly end-to-end register review with safe-custody inspection and key control.

    Weak evidence: A controlled-drugs register with no running balance kept at all, or a balance carried forward month after month that nobody has ever counted against the tablets and ampoules physically in the cabinet. A count that was done, showed a shortfall, and was noted but never investigated and never closed out. Entries written up in a batch from a scrap of paper at the end of a run, so the order in the register does not match the order things actually happened. Second signatures missing on entries the service's own standard operating procedure says should carry them.

    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.

  2. Destruction of stock Schedule 2 controlled drugs is witnessed and recorded by an Authorised Witness (not the Controlled Drugs Accountable Officer acting alone), while medicines returned by or belonging to a person are disposed of with a second competent witness as good practice, so the two routes are not conflated.

    Strong evidence: The destruction entry in the controlled-drugs register and the destruction log, plus the role separation stated in the policy (the CDAO cannot be the Authorised Witness for controlled-drug destruction).

    Weak evidence: Stock Schedule 2 controlled drugs denatured and destroyed with only the Controlled Drugs Accountable Officer signing and no separate Authorised Witness present. Patient-returned medicines and stock destruction recorded on the same line of one log so the two routes blur together, and neither shows the second signature its own route expects. A destruction log with quantities that cannot be traced back to the register entries they came from.

    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.

  3. The medicines administration record (MAR) is completed and signed at the time of administration, and every omission, refusal or unavailable dose is recorded with a reason and an action, so the colleague giving the next dose can tell what the person did and did not receive, not a blank box.

    Strong evidence: The MAR sample reviewed in the quarterly medicines audit (administration records against the local standard operating procedures), showing each administration and the reason any dose was not given recorded and signed at the time.

    Weak evidence: Blank boxes on the medicines administration record with no code and no explanation, a signature added later in a batch rather than at the time each dose was given, or a refused or unavailable dose left empty instead of coded with the reason and the action taken. Nobody reading the record afterwards can tell whether the person actually received the medicine.

    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.

  4. A medicines incident starts with a check that the person has come to no harm and medical help where it is needed, with the statutory-notification consideration kept as a separate question at the point of logging, and medicines incidents are reviewed together for patterns rather than treated as one worker's fault; the failure is an error logged with no harm check, no notification consideration, or closed as individual blame.

    Strong evidence: The incident logged the same shift through the incident-reporting policy, the harm check and medical-help step, the statutory-notification check run at log-time (serious medicines incidents may meet the trigger), and the medicines theme review that looks across incidents for patterns.

    Weak evidence: A medicines error logged with no record that anyone considered at log-time whether a statutory notification to the regulator was due, so there is no recorded decision either way, only a notification that never happened. No note of whether the person was checked for harm or medical help was sought. An incident closed against one worker's name with a training action and no look across recent medicines incidents for the pattern behind it.

    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.

  5. Covert administration only ever follows a recorded capacity assessment and a best-interests decision involving the prescriber and pharmacist, with a method agreed with the pharmacist, never a worker deciding alone.

    Strong evidence: The recorded capacity assessment, the best-interests decision record involving prescriber and pharmacist, and the pharmacist-agreed administration method.

    Weak evidence: Covert administration happening on a nurse's or manager's say-so with no recorded capacity assessment for that specific medicines decision at that time, or a capacity assessment borrowed from an unrelated decision. A best-interests record that does not involve the prescriber and pharmacist, or a medicine crushed into food with no method agreed with the pharmacist to confirm that crushing it is safe and does not change how the drug works.

    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. The level of medicines support for each person (prompting and reminding, assisting, or administering) is assessed, recorded and consented to, and reviewed when needs change, so a person who can manage their own medicines keeps doing so rather than being defaulted to full administration.

    Strong evidence: The care-plan record of medication needs and the recorded level of support, the consent or Mental Capacity Act best-interests record where capacity is in question, and the review recorded when needs change.

    Weak evidence: Every person defaulted to full administration with no assessment of what they can do for themselves, a care plan that does not name the level of support (prompting and reminding, assisting, or administering) or record consent to it, or a level set once at admission and never revisited when the person's ability or condition changed.

    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.

Related

Last verified 20 July 2026

Audit this policy

CQC medicines management audit checklist

A policy is the intent; the evidence is what a CQC inspector actually asks to see. This matching checklist turns the policy above into the records to keep, the audit to run, and the places small services most often fall short.

Open the CQC medicines management audit checklist

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Last reviewed 10 June 2026