Policy

Medicines Management Policy

Safe and effective handling, prescribing, administration and governance of medicines

For Private Healthcare ClinicRef BS-PH-POL-008See a sample (PDF) →
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  • Editable Microsoft Word (.docx)
  • Mapped to the CQC standards
  • Optional 3-monthly updates

What's inside

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

  • 1. Purpose
  • 2. Scope
  • 3. Policy statement
  • 4. Definitions
  • 5. Prescribing and Patient Group Directions
  • 6. Storage and security
  • 7. Administration
  • 8. Controlled Drugs
  • 9. Medicines reconciliation and transfers of care
  • 10. Disposal and waste
  • 11. Roles and responsibilities
  • 12. Training and competence
  • 13. Records, monitoring and audit
  • 14. Related documents
  • 15. Version control and review
  • Appendix A: Medicines administration safety checklist
  • Appendix B: Controlled Drug stock balance check log
  • 16. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 9 (Person-centred care), Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance)
  • Human Medicines Regulations 2012 (as amended)
  • Misuse of Drugs Act 1971 and Misuse of Drugs Regulations 2001 (as amended)
  • Misuse of Drugs (Safe Custody) Regulations 1973
  • The Controlled Drugs (Supervision of Management and Use) Regulations 2013
  • Nursing and Midwifery Council (NMC) standards for medicines management and the General Medical Council (GMC) guidance Good practice in prescribing and managing medicines and devices (2021)
  • National Institute for Health and Care Excellence (NICE) Guideline NG5 (Medicines optimisation) and NICE Guideline NG67 (Managing medicines for adults receiving social care)
  • Care Quality Commission (CQC) single assessment framework

Who it applies to

All clinical, nursing, pharmacy, prescribing and care staff (employed, bank, agency and locum), and any contractor or volunteer involved in any stage of the medicines pathway across [Organisation Name].

Glossary

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

Accountable Officer (Controlled Drugs)
The senior person who is legally responsible for the safe management and use of Controlled Drugs within an organisation.
Adverse drug reaction
An unwanted or harmful reaction experienced after taking a medicine at a normal dose.
Anaphylaxis
A severe, life-threatening allergic reaction needing immediate emergency treatment.
Anticoagulant
A medicine that thins the blood and slows clotting, which needs careful monitoring because of its risks.
Best interests
A decision made for someone who cannot decide for themselves, choosing the option that is best for them.
British Standard BS 2881
The official British safety standard that a Controlled Drugs storage cabinet must meet.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Central Alerting System (CAS)
A national service that issues safety alerts and important messages to healthcare providers.
Cold chain
Keeping vaccines and certain medicines within a safe temperature range from delivery to use.
Contemporaneous record
A record written at the time an event happens, or as soon as possible afterwards, so it is accurate and reliable.
Contraindicated
When a treatment or medicine should not be used because it could be harmful in a particular situation.
Controlled Drug (CD)
A medicine whose supply, storage and records are tightly restricted by law because of its potential for misuse.
Controlled Drugs Local Intelligence Network (CDLIN)
A local network that shares information and concerns about the safe use of Controlled Drugs between organisations.
Covert administration
Giving a medicine to someone in a hidden way, such as in food or drink, when they lack the capacity to consent and a best-interests decision allows it.
Cytotoxic and cytostatic medicines
Medicines (often used in cancer treatment) that are toxic to cells and must be handled and disposed of with special care.
Decontamination
The combined process of cleaning, disinfecting and, where needed, sterilising equipment so it is safe to reuse.
Denaturing
Making a Controlled Drug unusable, using an approved kit, before it is thrown away as waste.
Duty of candour
The legal duty to be open and honest with a person and their family when something goes wrong with their care.
General Medical Council (GMC)
The body that registers and regulates doctors in the United Kingdom.
General practitioner (GP)
A doctor based in the community who provides general medical care and coordinates a patient's wider treatment.
General sale list (GSL) medicine
A medicine that can be sold to the public without a prescription or pharmacist supervision, such as some everyday painkillers.
Good practice in prescribing and managing medicines and devices (2021)
Guidance from the General Medical Council setting out how doctors should prescribe and manage medicines safely.
Hazardous Waste (England and Wales) Regulations 2005
The law controlling how harmful waste, including certain medicines, must be stored, moved and disposed of.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that care providers must meet, enforced by the Care Quality Commission.
Informed consent
Agreement to treatment given freely after the risks, benefits and alternatives have been clearly explained.
Just culture
An approach to mistakes that focuses on learning and improvement rather than blaming individuals.
Medicines Administration Record (MAR / e-MAR)
The paper or electronic record showing which medicines have been given to a patient, when and by whom.
Medicines and Healthcare products Regulatory Agency (MHRA)
The body that regulates medicines and medical devices in the United Kingdom to make sure they are safe and effective.
Medicines optimisation
Helping people get the best possible outcomes from their medicines while reducing waste and harm.
Medicines reconciliation
Checking and comparing a person's medicines whenever their care moves between settings, to spot and fix any differences.
Mental capacity
Whether a person can understand and make a particular decision for themselves at the time it needs to be made.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
Misuse of Drugs (Safe Custody) Regulations 1973
The law setting out how Controlled Drugs must be stored securely, including the standard for storage cabinets.
Misuse of Drugs Regulations 2001
The law that classifies Controlled Drugs and sets the rules for their supply, storage and record-keeping.
National Institute for Health and Care Excellence (NICE)
The body that produces evidence-based guidance on treatments and care for health and social care services in England.
Near-miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Nominated Individual
The senior person responsible to the regulator for supervising how a service is provided.
Non-medical prescriber
A nurse, pharmacist or other registered professional, who is not a doctor, qualified to prescribe medicines within their competence.
Nursing and Midwifery Council (NMC)
The body that registers and regulates nurses and midwives in the United Kingdom.
Off-label use
Using a licensed medicine in a way not covered by its official approval, such as for a different condition or age group.
Patient Group Direction (PGD)
A written instruction letting named staff supply or give a medicine without an individual prescription.
Pharmacy (P) medicine
A medicine that can be bought without a prescription but only from a pharmacy and under a pharmacist's supervision.
Prescription-only medicine (POM)
A medicine that may lawfully be supplied only on the instruction of an appropriate prescriber.
Quarantine (of stock)
Setting aside medicines that may be unsafe so they cannot be used until they have been checked.
Records Management Code of Practice
National guidance on how health and care records should be kept, stored and eventually disposed of.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Shipman Inquiry
A public inquiry whose findings led to stronger controls over how Controlled Drugs are managed and monitored.
Single assessment framework
The structure the regulator uses to judge a service, built around quality statements and five key questions (safe, effective, caring, responsive, well-led).
Syringe driver
A small pump that delivers a measured dose of medicine steadily under the skin over a period of time.
The Controlled Drugs (Supervision of Management and Use) Regulations 2013
The law requiring organisations to appoint an Accountable Officer and to monitor the safe use of Controlled Drugs.
Unlicensed medicine
A medicine without a UK licence for the use intended, supplied only when a licensed option is not suitable and its use is justified.
Yellow Card Scheme
The national system run by the Medicines and Healthcare products Regulatory Agency for reporting suspected side effects of medicines and faulty devices.

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