Care Quality Commission
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CQC highlights continued improvement in the management of controlled drugs but warns that it needs to remain a priority through service changes

The Care Quality Commission (CQC) today published its fourth annual report on the safer management of controlled drugs regulations.

The Controlled Drugs (Supervision of Management and Use) Regulations 2006 were introduced in January 2007, placing responsibilities on organisations to make robust arrangements for the safe handling of controlled drugs and also investigate all reported concerns and share these findings with others. These regulations were introduced in response to the Shipman Inquiry, which found that ineffective monitoring had allowed Dr Harold Shipman to obtain large quantities of diamorphine, which he used to kill at least 15 and possibly over 200 patients, over a period of time without being detected.

Today’s report finds that there has been progress, with many instances of good innovative practice in the management of and sharing of concerns of controlled drugs. It is important that steps are taken to ensure this progress is maintained and the benefits of effective partnership working are not lost during the changes under way in primary care trusts (PCTs).

 CQC made the following recommendations.

  • Chief executives and accountable officers should continue to keep the safe management of controlled drugs a high priority on their organisation’s agenda during the reorganisation of the NHS to ensure that the gains in safety made over the past four years are not lost.
  • Chief executives and accountable officers should ensure that Controlled Drugs Local Intelligence Networks (CD LINs) have robust working arrangements and are fit for purpose and adequately prepared for the transition.
  • Non-designated bodies should also be encouraged to participate more in the information-sharing process to ensure that intelligence-gathering is thorough and complete, capturing information from all sources, e.g. community pharmacists, the Ministry of Defence, care homes, substance misuse services and new provider services.
  • All professionals and providers of care, whether practising in the NHS or independent sector, should take account of best practice guidance that is published by relevant professional bodies and agencies, and all sectors should be made aware of the document, 'Drug Misuse and dependence: UK guidelines on clinical management', and that it applies across all sectors.

Cynthia Bower, CQC's chief executive, said: “We all know that the NHS is going though a period of change at the moment, however it is vital that the excellent work carried out by health services demonstrated in this report isn’t neglected during this time of change.

“The regulations require relevant health care organisations to have an accountable officer who is responsible for monitoring controlled drugs. They also require providers, regulatory bodies and agencies to share information and investigate serious concerns and I would urge all health care providers to maintain focus on this important area.”


For further information please contact the CQC press office on 0207 448 9401 or out of hours on 07917 232143.

Notes to editors

Controlled drugs are a group of medicines that have the potential to be abused. For this reason they are ‘controlled’ by the Misuse of Drugs Act 1971 and subsequent regulations. Many controlled drugs are essential to modern clinical care. They include narcotics, such as morphine and diamorphine, which are used in a wide variety of clinical situations such as the relief of severe pain.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England. Our aim is to make sure that better care is provided for everyone, whether it is in hospital, in care homes, in people’s own homes, or anywhere else that care is provided. We also seek to protect the interests of people whose rights are restricted under the Mental Health Act. We promote the rights and interests of people who use services and we have a wide range of enforcement powers to take action on their behalf if services are unacceptably poor.

Under a new regulatory system introduced by government, the NHS, independent healthcare and adult social care must meet a single set of essential standards of quality and safety for the first time. We register health and adult social care services if they meet essential standards, we monitor them to make sure that they continue to do so and we respond quickly if there are concerns that standards are not being maintained. We do this by closely monitoring a wide range of information about the quality and safety of services, including the views of people who use services, and through assessment and inspection. The feedback from people who use services is a vital part of our dynamic system of regulation which places the views, experiences, health and wellbeing of people who use services at its centre.

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