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Procedure for handling controlled drug (CDs) discrepancy in care homes

For all staff responsible for dealing with discrepancies, incidents and errors related to CDs in care homes.

You can download a full pdf version of this document by following the link on the right.


This supporting guidance helps care home staff understand the procedure for dealing with discrepancies, incidents and errors related to CDs in care homes.

You must comply with the:


All care homes must have a standard operating procedure which details how to manage controlled drugs within the care home.

This should include:

  • what to do if there’ a discrepancy, error or near miss
  • how to review discrepancies and incidents.

When you identify a controlled drug discrepancy in a care home, you should take steps to establish what happened. In the first instance, discuss with a senior member of the care homes or care homes manager.

The discrepancy will need escalating if it can’t be explained or rectified. You must then take the following steps.

Who to inform

Contact details

Report the CD incident in accordance with the care home’s policy (which should include informing the resident’s GP) and local commissioning organisations.

Report it to the CQC if the medication error met the notification criteria, as outlined in regulations 16, 17, 18, and 20 of the CQC guidance for providers on meeting the regulations.

To be completed by the care home manager or deputy/senior manager in the absence of the manager.
The care home provider manager must report the incident to the local accountable officer via the CD reporting website.

You’ll need to create a user account.

Julie McCann, Local Accountable Officer  

Head of Pharmacy, Controlled Drugs Accountable Officer, Medication Safety Officer, NHS England South (South Central)

07900 715189 or 0113 825 3499

The care home manager should notify the care homes team at Buckinghamshire Healthcare Trust. They’ll tell you if you need to inform the CQC and the local safeguarding team depending on the circumstances. Lead Medicines Optimisation in Care Homes & Interface Pharmacist Older People, Unoma Okoli

07917 581724


PrescQipp Bulletin 75 | December 2014 Guidelines on the management of controlled drugs (CD) in care homes