💊 Beyond Compliance: What the CQC’s 2024 Controlled Drugs Report Means for Health and Social Care Providers

Lisa-Ann Basson, Consultant – PGQ Ltd

Suppose you are a provider in adult social care, a healthcare organisation, a CDAO, or a governance lead. In that case, the CQC's 2024 Annual Update on Controlled Drugs is not just a regulatory review. It is a definitive spotlight on how effectively systems across the country manage some of the most tightly regulated — and potentially hazardous — substances in care.

From residential homes to NHS Trusts, hospices to GP practices, the message is consistent: safe and effective controlled drug governance is non-negotiable.

At PGQ Ltd, we support services of all sizes to turn risk into resilience. Here's what the report tells us — and what you should be doing next.

📋 What the 2024 Report Covers

Published under the Controlled Drugs (Supervision of Management and Use) Regulations 2013, the CQC's report outlines:

• Oversight and activity by Controlled Drugs Accountable Officers (CDAOs)

• Prescribing and usage trends across sectors

• Findings from inspections, audits and governance reviews

• A summary of incidents, breaches, and learning

• Recommendations for improvement across all provider types

  
  

🔎 Key Findings Across the Sector

1. The CDAO Role Is Inconsistent

Some organisations have fully embedded CDAOs with clear accountability. Others still lack clarity, support, or senior-level engagement. This creates gaps in incident oversight, policy enforcement, and prescribing safety.

PGQ Tip: Assign a designated, trained CDAO. Guarantee their active participation in board-level governance and quality review cycles.

2. Storage, Record-Keeping and Reconciliation Are Still Problematic

The basics are still going wrong. The report found:

• Incomplete or illegible CD registers

• Missed or late stock reconciliations

• Lack of dual-signature protocols

• Unsafe disposal practices

• Patch misuse and PRN confusion in care homes

PGQ Tip: Conduct internal CD audits monthly, rotate auditors, and use a standardised reconciliation form. We can provide templates.

3. Incident Underreporting Is Widespread

Many services still fail to escalate or report CD incidents – either due to fear, poor training, or lack of process. Even serious errors are sometimes only recorded internally or missed altogether.

PGQ Tip: Establish a transparent culture around error reporting. Encourage staff to treat incidents as learning opportunities — not blame exercises.

4. Variation in Training and Competency

Staff competence varies hugely between and within services. The CQC highlighted that some staff administering high-risk medication have received no updated CD training in over 12 months, and that agency staff often lack service-specific induction.

PGQ Tip: Implement an annual CD training schedule. Use competency-based assessments, not just theoretical modules.

5. Monitoring and Prescribing Patterns Need More Oversight

CD prescribing patterns, especially in GP practices, hospices, and outpatient services, demonstrated notable variation, with high or unusual prescribing often not receiving a comprehensive review.

PGQ Tip: CDAOs should regularly audit prescribing data and investigate outliers. Clinical governance teams must triangulate MAR charts, GP records, and pharmacy logs.

🧠 What This Means for All Providers

Whether you operate in:

• NHS Trusts

• Hospices

• Community health services

• Private mental health hospitals

• Residential or nursing care

• Primary care or urgent care centres

…your organisation is expected to have:✅ Safe storage✅ Accurate records✅ Robust incident management✅ Effective CDAO leadership✅ Competent, trained staff✅ Clear policy and procedures

🔧 What PGQ Ltd Can Do for You

At PGQ Ltd, we offer tailored support grounded in real-life expertise and aligned to the CQC's Quality Statements and Medicines Optimisation priorities.

Our services include:

PGQ Support Service	Outcomes
Policy Development & Review	Updated CD policies tailored to your service type
Governance & Audit Tools	Templates and systems for regular internal checks
Staff & Manager Training	Scenario-based, competency-focused training sessions
Mock Inspections & Spot Audits	Uncover gaps before CQC or NHS England do
Incident Investigation & Learning	Root cause analysis tools and reflective practice coaching
Leadership Coaching	Support for Registered Managers and CDAOs in fulfilling their regulatory responsibilities

📥 Resources Available Now

We've created a complete toolkit in response to this year's CQC update, including:

• ✔️ PowerPoint training deck on controlled drugs

• ✔️ Competency checklists for care staff and managers

• ✔️ Audit templates for internal use

• ✔️ Handouts and training guides for frontline teams

All fully customisable and available as branded PGQ materials.

✅ Controlled Drugs: Step-by-Step Process for Care Staff

Administering controlled drugs (CDs) safely and lawfully is a vital part of your role in care. These medicines are highly regulated for a reason — they carry serious risks if mishandled.

This quick guide will walk you through the correct steps to follow, from the moment a CD enters your service to ongoing checks and reporting.

🔄 The Controlled Drug Administration Process: Step-by-Step

1. Receiving a Controlled Drug Delivery

When CDs arrive from the pharmacy:

• ✅ Check the delivery against the prescription and delivery note

• ✅ Inspect for damaged packaging or missing items

• ✅ Record in the Controlled Drug Register immediately — including:

  • Name, form, strength, and quantity

  • Date received

  • Signature of the person receiving

  • Signature of the delivery person (if possible)

    
    

2. Safe Storage

• ✅ CDs must be stored in a locked CD cabinet fixed to the wall

• ✅ Access should be restricted to authorised, trained staff

• ✅ Keep the CD keys securely, in line with your service policy

  
  

3. Preparing for Administration

Before giving the medication:

• ✅ Double-check the MAR chart, prescription, and CD register

• ✅ Confirm:

  • Right resident

  • Right medicine

  • Right dose

  • Right time

  • Correct route (oral, patch, injectable)

• ✅ Get a second staff member to witness the preparation and administration (required for most CDs)

  
  

4. Administering the Medication

• ✅ Explain the medication to the service user

• ✅ Administer using correct PPE and infection control protocols

• ✅ Ensure the resident has taken the medication fully (do not leave CDs unattended)

  
  

5. Recording After Administration

• ✅ Record the administration in the CD Register:

  • Time, date, amount given

  • Balance remaining

  • Signatures of both staff members

• ✅ Record on the MAR chart

• ✅ If a dose is refused, missed, or wasted, clearly document and follow your service protocol

  
  

6. Daily Stock Checks

• ✅ Two trained staff members should carry out at least one daily stock count

• ✅ The actual stock must match the CD register — if not:

  • Report immediately to the manager or CDAO

  • Do not alter records — follow incident reporting protocol

    
    

7. Reporting and Disposal

• ✅ Report any:

  • Discrepancies

  • Errors

  • Near misses

  • Suspicions of misuse or diversion

    
    

• ✅ For expired or discontinued CDs:

  • Follow your policy for safe disposal

  • Use a denaturing kit and record disposal in the register

  • Always witness disposal with two staff and sign

    
    

👥 Your Responsibilities

As a staff member who handles CDs, you must:

• Be trained and competent

• Follow your service's standard operating procedures (SOPs)

• Report concerns immediately to your line manager

• Keep all CD records clear, accurate, and timely

  
  

🧠 PGQ Tip:

Don't just rely on routine — stay vigilant. If something doesn't look right, say something. Whether it's a missing dose, a mislabelled pack, or an error in the register, your attention could prevent harm.

The Board of Directors and provider leadership play a critical governance role in ensuring the safe and lawful management of controlled drugs (CDs). Their responsibilities extend beyond policy approval — they must ensure there is active oversight, accountability, and support at every level of the organisation, especially for Registered Managers.

Here's a breakdown of what the board must do and how providers should support Registered Managers.

🏛️ Board-Level Duties for Controlled Drug Safety

1. Set the Tone for Accountability and Safety

• Establish a zero-tolerance culture for poor CD management.

• Ensure that CD safety is included in clinical and corporate risk registers.

  
  

2. Appoint and Support the CDAO

• Ensure there is a formally appointed Controlled Drugs Accountable Officer (CDAO) who is:

  • Competent and trained

  • Senior enough to influence change

  • Resourced to carry out the role effectively

• Review the CDAO's annual report and escalation actions

  
  

3. Ensure Policy and Process Oversight

• Approve and regularly review the organisation's Controlled Drug Policies and SOPs.

• Ensure that policies are cascaded to services and implemented in practice.

  
  

4. Scrutinise Incident Data and Learning

• Monitor trends in CD errors, near misses, and incidents through governance reports

• Ensure that learning from investigations is actioned and embedded

• Expect regular updates on stock reconciliation, training compliance, and audit findings

  
  

5. Champion Training and Competence

• Hold leadership accountable for delivering role-specific, up-to-date training

• Ensure managers and frontline staff are assessed for competency, not just attendance

  
  

6. Demand Evidence of Assurance

• Request regular mock inspection outcomes, internal audit results, and CQC updates

• Challenge services that repeatedly fail to meet CD requirements or have avoidable incidents

  
  

🤝 Provider Responsibilities: Supporting Registered Managers

The provider (i.e., regional directors, nominated individuals, head office teams) must empower and equip Registered Managers to lead on controlled drug safety at the service level.

Here's how:

Support Area	Actions Required
Training & Competency	Provide tailored training and refreshers for managers on CD regulations, incident handling, and audit.s
Policies & Tools	Ensure managers have clear, easy-to-follow SOPs, CD registers, reconciliation tools, and reporting forms.
Incident Support	Offer hands-on guidance with root cause analysis (RCA), escalation protocols, and regulator communication.
Audit & Monitoring	Conduct regular regional spot checks and governance visits to support consistency and accuracy.
Emotional & Operational Support	Recognise the stress of medication incidents — provide supervision, coaching, and protected time to investigate or report CD issues.
Tech Systems	Invest in digital MAR charts, audit software, and dashboards that help managers track and escalate issues proactively

🧠 PGQ Insight

“We’ve worked with services where the Registered Manager was doing everything right — but lacked the provider-level systems or head office support to sustain safe CD practice. Good CD governance isn’t about one person — it’s a leadership system.”

💬 Final Thoughts

This year's report isn't just about policy — it's about people. At its heart, controlled drug governance protects vulnerable individuals from harm. That's a responsibility none of us should take lightly.

If your organisation isn't confident in its CD systems — or if you want an objective review before your next inspection — get in touch with PGQ today. Let's make safe practice second nature.