Controlled Drugs Policy

With respect to the prescribing, supply, storage and administration of medicines, this home adheres fully to the Medicines Act 1968, the Misuse of Drugs Act 1971, the Misuse of Drugs (Safe Custody) Regulations 1973, the Controlled Drugs (Supervision of Management and Use) Regulations 2013 and the Nursing and Midwifery Council Guidelines for the Administration of Medicines.

In addition to the above, the home complies fully with Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, “Management of Medicines”, which states that the registered person must, so far as reasonably practicable, ensure that medicines are handled safely, securely and appropriately, including controlled drugs.

The home understands that in order to maintain its registration with the Care Quality Commission it must comply with Guidance about Compliance: Essential Standards of Quality and Safety, Outcome 9 of which requires clear procedures to be in place covering arrangements for reporting adverse events, adverse drug reactions, incidents, errors and near-misses. These should encourage local and, where applicable, national reporting, learning and promoting an open and fair culture of safety.


Controlled drugs are those that have been agreed as potentially addictive or dangerous and thus require special provisions if they are to be used. The Misuse of Drugs Act 1971 is concerned with controlled drugs and classifies them into five schedules (which includes Schedule 2 drugs, eg morphine).

In this home the following applies.

  1.  Controlled drugs must be kept in the lockable metal cupboard specifically provided for the purpose. The cupboard is secured to a solid wall and has a double lock mechanism and complies with legislation.
  2.  The controlled drugs cupboard must be kept locked at all times. Access to the cupboard is limited to approved staff only.
  3.  Controlled drugs coming into the home must be checked in by an approved person and witnessed by the pharmacist or a designated member of staff. The name of the resident, quantify of medication, and type and date of medication should be recorded in the Controlled Drugs Register and the medication immediately transferred to the controlled drugs cupboard and locked away.
  4.  Different strengths and forms of the same medication should be entered on separate pages and a new page should be started for each new receipt.
  5.  The total balance of drugs in stock will be recorded and any returns to the pharmacy must be signed for by a designated person. Any discrepancy in the quantity should be reported immediately to the pharmacist concerned.
  6.  When controlled drugs are administered by nursing or care staff, a second appropriately trained member of staff should be on hand to double-check the dose. Both members of staff must witness the resident taking the medication and both should sign the Controlled Drugs Register and relevant medicine administration record (MAR) chart.
  7.  Extreme care must be taken when measuring volumes of liquids and staff should always read-off volumes from the bottom of the meniscus at eye level to avoid errors.
  8.  If a dose is refused, or only partly taken, both members of staff must witness the disposal of the remaining medication, record the details and sign to that effect in the Controlled Drugs Register and on the MAR chart.
  9.  Where a controlled drug dose is refused the resident’s GP should be contacted for advice if the resident’s health or wellbeing is at risk due to the refusal.
  10.  If a tablet is dropped on the floor or somehow spoilt, an entry should be made in the register and witnessed by a second member of staff. The tablet should then be stored in the controlled drugs cupboard awaiting disposal.
  11.  Stock checks should be conducted daily by two approved members of staff who should note all quantities and make an appropriate entry in the register. Any discrepancies should be communicated to the care home manager immediately.
  12.  Any adverse events, incidents, errors and near-misses involving controlled drugs should be handled according to the Drug Errors Policy and thoroughly investigated.
  13.  Where a self-medicating resident uses a controlled drug, a risk assessment should be conducted regarding the safety of the resident self-administering the drug and storing it in their room with the rest of their medication.
  14.  Where the risk assessment suggests that it would be safe and appropriate for the resident to keep and administer the drug themselves, sensible precautions should be put in place to ensure that controlled drugs are not stolen from the resident or left lying around.
  15.  When the resident manages their own medication and is wholly independent (ie he or she is responsible for requesting a prescription and collecting the controlled drugs personally from the pharmacy) there is no need to keep a record in the Controlled Drugs Register.
  16.  When a resident’s controlled drugs are no longer required they should be disposed of safely using the controlled drug disposal kit and a record kept in the Controlled Drugs Register of who returned them, the quantity and the date. This disposal should be witnessed.


All staff are responsible for the implementation of this policy. Overall responsibility for ensuring that the policy is implemented, monitored and reviewed rests with the care home manager. Information on the policy will be:

  • circulated to all staff
  • provided to all new employees
  • included in the Administration of Medication Policy.

The care home manager will ensure that the procedures contained within this policy are followed by all staff and will ensure that all staff expected to deal with controlled drugs are aware of how to access the policy. The manager will identify any areas of significant risk and take action to control this risk, promoting and demonstrating good practice associated with controlled drug use at all times.

All staff dealing with controlled drugs will ensure they are familiar with this policy and will be expected to follow the correct procedure when undertaking any task involving controlled drugs. They must report any concerns relating to the risks associated with controlled drugs to the care home manager or the relevant pharmacist so action can be taken.


All new staff will be encouraged to read this policy as part of their induction process. Those with specific duties and responsibilities under the policy will be offered additional training.



Signed: ________________________________
Date: ________________________________
Policy review date: ________________________________

Latest Amendments

Updated to reflect the fact that the Safer Management of Controlled Drugs Regulations 2006 have been superseded by the Controlled Drugs (Supervision of Management and Use) Regulations 2013.