Standard operating procedure

Cold Chain Management Procedure

The step-by-step procedure for storing, monitoring and protecting refrigerated medicines - notably botulinum toxin - within the 2 to 8 degrees Celsius range, and for acting on temperature excursions and fridge failure.

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment and materials
  • 6. Procedure
  • 7. Temperature excursion - actions
  • 8. Fridge failure or power loss plan
  • 9. Records
  • 10. Related documents
  • 11. Review and version control
  • 12. Disclaimer

Legislation & standards it maps to

  • Human Medicines Regulations 2012
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 12 (Safe care and treatment)
  • The product Summary of Product Characteristics (SmPC) storage requirements for each refrigerated medicine
  • Medicines and Healthcare products Regulatory Agency (MHRA) guidance on the control and monitoring of storage temperatures for medicines

Who it applies to

All practitioners, prescribers, registered nurses and support staff at [Organisation Name] who order, receive, store, monitor or handle refrigerated (cold-chain) medicines and products.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Accredited service
A service provider that has been formally approved to a recognised standard to carry out work such as servicing or calibration.
Adjunct
An additional medicine or product used to support a main treatment.
Adverse incident
Any unexpected or unwanted event linked to care or treatment that harms, or could harm, a patient.
Batch number
A code identifying the specific production run of a medicine, used to trace and recall stock if needed.
Botulinum toxin
A prescription-only injectable medicine, used in aesthetic and clinical treatments, that must be kept refrigerated to remain safe and effective.
Calibration
Checking and adjusting a measuring device, such as a thermometer, against a known standard so its readings can be trusted.
Cold chain
The unbroken run of refrigerated storage and handling that keeps a product within its safe temperature range from manufacture through delivery to use.
Contemporaneous
Recorded at the time the event happened, or as soon as possible afterwards, so the record is accurate and reliable.
Data logger
An electronic device that records temperature continuously over time and can raise an alarm if readings go out of range.
Decontamination
The combined process of cleaning, disinfecting and, where needed, sterilising equipment so it is safe to reuse.
Efficacy / effectiveness
How well a medicine produces the intended result when used correctly.
Falsified medicine
A medicine that has been deliberately and fraudulently misrepresented, for example a fake product or one with a false source or contents.
Formulation
The particular form a medicine comes in, such as a solution, powder or pre-filled syringe.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that providers of regulated care must meet, enforced by the Care Quality Commission.
Human Medicines Regulations 2012
The main United Kingdom law governing the licensing, supply, storage and handling of medicines for human use.
Maximum/minimum thermometer
A calibrated thermometer that shows the highest and lowest temperatures reached since it was last reset, as well as the current temperature.
Medicines and Healthcare products Regulatory Agency (MHRA)
The United Kingdom body that regulates medicines and medical devices and issues guidance on their safe handling and storage.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Pharmaceutical / clinical waste
Waste from medicines and healthcare activities that must be segregated and disposed of safely under waste-handling rules.
Prescription-only medicine (POM)
A medicine that may lawfully be supplied only on the instruction of an appropriate prescriber.
Quarantine
Setting affected stock aside and clearly marking it so it cannot be used until a decision on its safety has been made.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Regulation 12 (Safe care and treatment)
The part of the regulated-activities regulations requiring care and treatment to be provided in a safe way, including the safe management of medicines.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Standard Operating Procedure (SOP)
A written set of step-by-step instructions that staff must follow to carry out a task safely and consistently.
Stock rotation (first-to-expire, first-out)
Arranging stock so the items with the nearest expiry date are used first, reducing waste and the risk of using expired products.
Summary of Product Characteristics (SmPC)
The manufacturer's licensed information for a medicine, including how it must be stored and used.
Temperature excursion
Any recorded temperature outside the required 2 to 8 degrees Celsius range, or any reading suggesting the range may have been breached.
Thermostat
The control that sets and maintains the target temperature inside a refrigerator.
Validated alternative store
A backup storage method, such as a cool box with conditioned ice packs, that has been checked to keep stock within the required temperature range.
Wholesaler
A licensed business that supplies medicines in bulk to pharmacies and healthcare providers.

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