Controlled Drugs in Care Homes: Register, Storage, Disposal

Controlled drugs in care homes are governed by the Misuse of Drugs Regulations 2001 and the safe custody rules that sit alongside them, with NICE guideline SC1 and CQC guidance setting out what good practice looks like. In practice that means a CD cupboard that meets the safe custody rules, a CD register with a running balance (a bound book with numbered pages, or an electronic register that meets the legal requirements), a trained second person witnessing wherever possible, regular balance checks, and a clear route for reporting anything that does not add up. None of it is complicated. All of it has to be done every time.

The short answer

A controlled drug is a medicine listed in the schedules to the regulations because of its potential for misuse. In a care home the ones you will meet are mostly opioid painkillers such as morphine, oxycodone and fentanyl, and some sedatives such as temazepam and midazolam. Schedule 2 drugs, and some Schedule 3 drugs such as temazepam and buprenorphine, must be kept in a CD cupboard that meets the safe custody rules. Every movement of a Schedule 2 drug (receipt, administration, disposal and transfer) goes in the CD register, with a running balance. CQC calls it good practice for two trained staff to witness and sign receipt, administration and disposal. NICE SC1 recommends that the person giving a controlled drug and a trained witness both sign the register. Check balances regularly, and investigate and report any discrepancy. The rest of this guide goes through each of those steps as a manager would.

What counts as a controlled drug

The regulations sort controlled drugs into five schedules. Schedule 1 covers drugs with no medical use and will not appear in a care home. Schedule 2 is the group that carries the full set of requirements: morphine, diamorphine, oxycodone, fentanyl, methadone, methylphenidate and others. Schedule 3 includes temazepam, buprenorphine, midazolam, tramadol, gabapentin and pregabalin, with lighter requirements and some variation about which need safe custody. Schedule 4 covers most benzodiazepines such as diazepam and lorazepam, and the z-drugs. Schedule 5 covers low-strength preparations such as codeine linctus, co-codamol and morphine sulfate oral solution 10mg/5ml (Oramorph).

The practical point for a manager is this. Schedule 2 drugs go in the CD cupboard and the CD register. Some Schedule 3 drugs, such as temazepam and buprenorphine, must go in the CD cupboard but do not legally need a register entry. Other Schedule 3 drugs (for example midazolam, pregabalin, gabapentin and tramadol) and Schedules 4 and 5 need neither. They must still be stored securely, with accurate records of receipt, administration and disposal. Many homes record some of them in the register as well, particularly where there is a risk of diversion, so follow your policy. Your pharmacist can confirm the schedule of any medicine, and your medicines policy should list which ones your home treats as controlled.

At a glance: schedules and what applies in a care home

Schedule	Examples	Safe custody cabinet	CD register	Witness
2	Morphine, oxycodone, fentanyl, methadone, methylphenidate	Yes	Yes	Expected
3 with safe custody	Temazepam, buprenorphine	Yes	Not required by law; some policies require it	Expected by most policies
3 without safe custody	Tramadol, gabapentin, pregabalin, midazolam	Not required, often done	Policy choice	Policy choice
4	Diazepam, lorazepam, zopiclone, most benzodiazepines	No	No	No, though many homes count them
5	Co-codamol, low-strength codeine preparations, Oramorph 10mg/5ml	No	No	No

The table is a guide, not a substitute for checking. Where it says no cupboard, the medicine still has to be stored securely. Schedules change, and the regulations have been amended several times in the last decade. When a new medicine arrives, ask the pharmacy which schedule it is in and record the answer.

The law: what the Misuse of Drugs Regulations actually require

The Misuse of Drugs Regulations 2001 set out who may possess, supply and administer controlled drugs and what records must be kept. The Misuse of Drugs (Safe Custody) Regulations 1973 set the standard for the cabinet. Together they are the legal floor. For a care home the main obligations are that Schedule 2 and safe-custody Schedule 3 medicines are kept in a cabinet that meets the standard, that they are only administered by or under the direction of a registered practitioner in line with the prescription, and that records of receipt and administration are kept.

CQC's guidance is direct. Unless a person is looking after their own medicines, you must store Schedule 2 drugs in a CD cupboard and record every movement of them in a CD register, in homes with and without nursing. Schedule 3 drugs do not need register entries, though your policy may ask for them. Keep registers for at least two years from the last entry (the period the Misuse of Drugs Regulations 2001 set for CD registers), and longer if your policy says so.

The rules also cover disposal, and they differ between homes with and without nursing. A care home may never simply throw controlled drugs away. Returns and disposal, below, sets out what each type of home must do.

What NICE SC1 and the CQC medication administration guidelines say

NICE SC1, the guideline on managing medicines in care homes, is the document inspectors use to judge medicines practice. It says providers of adult care homes must comply with the Misuse of Drugs Act 1971 and its regulations when storing controlled drugs (recommendation 1.12.1). It says the member of staff giving a controlled drug and a trained witness should both sign the CD register, with the person giving it also signing the MAR (1.14.16). And it recommends an annual review of every staff member's medicines knowledge, skills and competence (1.17.5).

CQC's guidance on controlled drugs in care homes says you must have a policy or standard operating procedure covering ordering, storing, administering, recording and disposal. It must include what to do about a discrepancy and who to contact, including your regional NHS England controlled drugs accountable officer (CDAO) or the police. Inspection adds its own angle. Inspectors will look at the cabinet, open the register, pick a medicine and count it against the running balance, check that the witness signatures are real people who were on shift, and ask what happened the last time a balance was wrong. They will also ask how the home reports concerns to the Controlled Drugs Accountable Officer.

Neither document is long. Every registered manager should have read both and should be able to point to where the home's policy reflects them. If your policy was written before 2014 and has not been reviewed against SC1, it is out of date.

The CD register

On paper, the register is a bound book with numbered pages. Loose-leaf folders are not acceptable because pages can be removed without trace. CQC confirms that electronic registers are permitted instead. Entries must be attributable to the person who made them, secure, and able to be audited, including any corrections. The register must comply with best practice and be accessible from the care home and printable. A spreadsheet anyone can edit without trace does not meet that. Each controlled drug for each resident has its own page, and where a resident has the same medicine in two strengths or two forms, each has its own page.

Every entry records the date and time, what happened (received, administered, returned, destroyed), the quantity, the resident's name, the running balance after the transaction, and the signatures of the person making the entry and the witness. Entries are made in ink, as soon as possible on the same day, in chronological order. Entries are never cancelled, altered or crossed out. A correction is signed and dated in the margin or as a footnote. Whenever possible, a suitably trained member of staff witnesses and signs each entry too.

When a page is full, the balance is carried forward to a new page and both pages cross-reference each other. When a resident leaves or dies, the balance is returned or destroyed and the page is closed with the final entry showing zero. Registers are kept for two years from the last entry, and in practice most homes keep them longer.

Storage: the CD cabinet

The cupboard must meet the Misuse of Drugs (Safe Custody) Regulations 1973, and your supplier will confirm whether a cupboard complies. In practice that means a metal cabinet fixed to a solid wall or floor with a compliant lock, and it is sensible not to label it in a way that advertises what it holds. A cabinet inside a locked medicines room is normal, but the room lock is not enough on its own. Do not use it for other items such as jewellery or money, restrict access to those who need it, and store spare keys securely.

Key security is the point most often found wanting. There are no national rules about which staff hold the CD keys. CQC expects providers to decide by risk assessment and write it into the CD policy. Most homes give them to the person in charge of medicines on that shift, carried on their person, not left in a drawer or on a hook. There is a record of who holds them at handover. A lost key is a security incident, not an inconvenience, and the lock is changed.

Controlled drugs with safe custody requirements that need refrigeration, which is rare in a care home, go in a locked medicines fridge. Keep them separate from other medicines, ideally in a lockable box with restricted access, as CQC suggests. Controlled drugs sent out with a resident on leave are recorded out of the register and back in on return, with the quantities checked both ways.

Receiving controlled drugs into the home

A delivery of controlled drugs is checked on arrival by two people. They compare the medicine, strength, form and quantity against the delivery note and the prescription, enter the receipt in the register with the running balance, and both sign. The delivery note is kept with the medicines records. Any discrepancy between what was ordered, what the note says and what is in the bag is raised with the pharmacy immediately and recorded.

Receipt is where a surprising number of balance problems begin. The pharmacy sends thirty, the note says twenty-eight, the worker signs for thirty, and six weeks later the count is two short and nobody knows why. Two people counting on the day prevents that.

Administering a controlled drug: the procedure

This is the sequence for a single dose. It takes a minute or two once staff are used to it.

Check the MAR chart or eMAR for the dose due, the prescription, and any PRN protocol or parameters.
Both the administering worker and the witness go to the cabinet together. Neither handles the medicine alone.
Open the register to the resident's page for that medicine and check the running balance against the stock in the cabinet before removing anything.
Remove the dose. Check the label, the strength, the form and the expiry against the prescription.
Both count the remaining stock and confirm it matches the new balance.
Make the register entry: date, time, resident, quantity given, new balance, both signatures.
Lock the cabinet, return the keys to the key holder.
Administer the dose to the resident, with the witness watching it being taken.
Record the administration on the MAR chart or eMAR, with both signatures where the system requires it.
If any part of the dose is not taken, record it as refused or destroyed in the register and on the MAR, and dispose of it with the witness.

The register entry is made as soon as the witnessed dose has been given, and always the same day, so the running balance never drifts from the cupboard. Some homes record the MAR at the same time; either way both records are made within the same few minutes. Some homes record the MAR at the same time; either way both records are made within the same few minutes.

The witness: who and why

The witness is a second person who watches the whole process and countersigns. Their job is to check the count, check the dose against the prescription, and see it given. They are not a signature collected afterwards. The witness must be trained and competent in medicines administration. In a nursing home they are usually another nurse or a senior carer; in a residential or learning disability home they are another trained medicines worker. A cleaner, a visitor or a resident cannot witness.

The witness protects everyone. It makes an honest error much less likely to reach the resident, because two people are checking. It makes diversion much harder, because two people have to collude. And it protects the worker, because a balance that is wrong at the next check can be traced to an entry that two people signed.

On a night shift with one trained worker the home has a problem, and the honest answer is to plan the rota so it does not happen. If it cannot be avoided, the policy must say what the single worker does, and the audit must show how often it happened. An electronic register that won't accept a controlled drug entry without a named witness makes witnessing part of the process rather than something remembered later. In Kiwi, a controlled drug can't be signed, booked in or disposed of without naming a second member of staff as witness.

Recording on the MAR chart and the eMAR

The register records the stock. The MAR chart records the administration. Both are needed, and they must agree. A dose in the register with no MAR entry, or a MAR entry with no register entry, is a discrepancy, and the monthly audit should look for both.

On paper the MAR box carries the administering worker's initials, and many homes add the witness initials alongside. On an eMAR the system records the administering user and the witnessing user with the time, and can carry a running balance that should match the register. Where they differ, the register is the legal record and the eMAR is the evidence of what happened, and the difference must be investigated rather than adjusted. The guide to MAR chart codes explains how refusals and destroyed doses are coded so the two records line up.

In Kiwi, a controlled drug can't be signed without naming a second member of staff as witness. Each scheduled dose is recorded as taken, refused, missed or not required, with the staff member's name and the time, and each person's MAR chart downloads as a PDF for the last 28 days with the code key.

Balance checks and how often to do them

CQC says care homes need to keep a running balance of each controlled drug, which makes discrepancies much easier to spot. Neither CQC nor NICE sets a national frequency for full balance checks, so your policy sets it, based on your home. In a nursing home with a large stock of opioids, many homes check at every handover. In a residential home with two residents on temazepam, a weekly check may be enough. The policy sets the frequency and the audit shows it was kept.

A balance check means two people count the physical stock of every controlled drug and compare each count with the running balance in the register, then sign and date the check in the register or in a separate balance check book. Every discrepancy, however small, is recorded and investigated the same day. Do not adjust the register to match the count. Investigate, find the cause, record it, and then correct the register with a signed, dated, explained entry.

Liquids are the exception that needs judgement. Measured volumes drift because of residue in the bottle and the measuring device. A small, consistent shortfall on a liquid is usually explained by that and should be recorded as such, but a shortfall that grows or appears suddenly is not.

When the balance is wrong

The first thing is to stop and think, not to panic and not to cover. Recount with a different second person. Check the register for arithmetic errors, which cause most discrepancies. Check the MAR for a dose given and not entered in the register. Check whether a dose was returned, sent on leave, or destroyed without an entry. Check the delivery note against the receipt entry.

If the cause is found, record it in full: what the discrepancy was, what caused it, who investigated, what was done. Make the correcting entry. Review whether the process needs to change. If the cause is not found, the discrepancy is unexplained and must be reported: to the registered manager and the provider, to the Controlled Drugs Accountable Officer for your region, to CQC by notification if the threshold is met, and to the police if theft is suspected. Safeguarding may also need to be involved if a resident may have been affected.

An unexplained loss that is reported promptly and investigated properly is a serious event handled well. An unexplained loss that is discovered by an inspector is a different matter. The guide to medication errors in care homes covers the investigation process in more detail.

Refused, dropped and part doses

A controlled drug that leaves the cabinet and does not go into the resident still has to be accounted for. If the resident refuses, record it in the register with a witness and the reason. In a home without nursing, follow the process agreed with your pharmacy: usually the dose goes in a labelled tamper-proof container, kept in the CD cupboard apart from current stock until it is returned to the pharmacy. In a home with nursing that holds a T28 waste exemption, denature it with a witness and record the destruction with two signatures. The MAR shows the refusal code. The dose is not put back in the pack or the bottle.

A dropped tablet is treated the same way. A part dose, for example half a tablet where the prescription is for half, means the other half is either kept for the next dose in a labelled container, if the policy allows, or destroyed. Either way it is recorded. A liquid dose drawn up and not used is disposed of in the same way and recorded.

These events are where balances go wrong most often, because the worker is dealing with a distressed resident and the paperwork feels secondary. Build them into training with worked examples.

Returns and disposal

Controlled drugs that are no longer needed, because the prescription changed, the resident left or died, or they expired, are separated from current stock and recorded out of the register with a witness and the new balance. What happens next depends on the type of home.

Care homes without nursing: return all medicines, including controlled drugs, promptly to a community pharmacy. Keep them in the CD cupboard until they go. The pharmacy denatures them, so you do not need a T28 waste exemption. One member of staff records the return and a second checks and signs; some pharmacists also sign the register, but this is not a legal requirement.

Care homes with nursing, residents' own medicines: individually labelled Schedule 2, 3 and 4 (Part I) controlled drugs must be denatured before they go to the waste disposal company. You need a T28 waste exemption from the Environment Agency, which is free. One member of staff records the destruction and a second witnesses and signs.

Care homes with nursing, stock controlled drugs: out-of-date Schedule 2 stock must be destroyed in the presence of an authorised witness, such as a police constable, a General Pharmaceutical Council inspector or a person appointed by the NHS England CDAO, and recorded in the register. It is good practice for another member of staff to witness the denaturing of Schedule 3 and 4 (Part I) stock.

When a resident dies, keep their medicines, including controlled drugs, until any investigations such as a coroner's inquest are complete, as CQC advises. Many local policies set a minimum of seven days. Then dispose of them as above. The register entry records the date of death and the disposal.

Expired controlled drugs are disposed of the same way. They are never left in the cabinet, because they inflate the stock and confuse the count.

Patches, liquids and other forms

Fentanyl and buprenorphine patches are controlled drugs and need the same register and witness. Because the patch stays on the resident for days, the record must also show where it was applied, when it was removed, and that the removed patch was folded in half, sticky sides together, and disposed of in line with your policy (many require a witness). CQC expects records of the site of application and how the site is rotated. A patch chart or body map is the sensible way to do it, and a used patch that cannot be found is a discrepancy.

Oral liquids are measured with an oral syringe, never a spoon, and register entries record the volume in millilitres. Check the strength. Morphine sulfate oral solution 10mg/5ml (Oramorph) is Schedule 5, so the law does not require a register entry, though CQC expects accurate records of receipt, administration and disposal and many homes record it in the register by policy. Stronger morphine oral solutions, and oxycodone liquids, are Schedule 2. Small shortfalls are normal and should be explained in the balance check. Injectable controlled drugs, mostly in nursing homes for end-of-life care, are recorded by ampoule, and a part ampoule is destroyed and recorded.

Residents' own controlled drugs and self-administration

Some residents, particularly in mental health and learning disability services, manage some of their own medicines. That can include a controlled drug where the risk assessment supports it, but it is unusual and the assessment must be specific to that medicine. The home still needs to know what the resident holds, where it is kept, and how the resident's stock is reconciled.

Where the home is holding a resident's own controlled drug, for example one brought in on admission, it is entered in the register on receipt like any other, and the resident's consent to the home holding it is recorded in the care plan.

Social leave and hospital

When a resident goes out for the weekend and takes a controlled drug with them, the quantity sent is entered out of the register with a witness, and the quantity returned is entered back in, with any difference explained by the doses given while away. The family or carer signs for what they took. When a resident goes into hospital, their controlled drugs usually go with them, and the same process applies; anything not returned is chased with the ward and recorded.

These transactions are where the register and the eMAR most often fall out of step, because the leave is arranged in a hurry. A short procedure and a checklist at the door prevent it.

Controlled drugs in learning disability and mental health services

In these services the controlled drugs you meet may include sedatives and anticonvulsants as well as opioids, for example buccal midazolam for prolonged seizures, and many are prescribed PRN. Any medicine used for distressed behaviour should be reviewed regularly with the prescriber, in line with STOMP. Register and CD cupboard rules depend on the drug's schedule (see above). Midazolam, for example, needs neither. Kiwi asks for a named witness for every medicine you mark as a controlled drug. The additional discipline is in the PRN protocol: when the medicine may be used, what must be tried first, the maximum in twenty-four hours, and how the outcome is recorded. Every PRN dose of a controlled drug should be reviewable against the protocol, and a pattern of increasing use is a clinical question for the prescriber, not an operational one for the home.

Capacity and consent matter here too. A resident who refuses a controlled drug may be exercising a choice or may lack capacity for that decision, and the care plan must say which and what follows. Restraint to administer a controlled drug is a serious step that needs a lawful basis and is never a routine matter.

The controlled drugs audit

The monthly medicines audit should include a controlled drugs section, and a fuller controlled drugs audit should be done quarterly. Work through this list.

The cabinet meets the safe custody standard and is locked, and the keys are held by the named person.
Every controlled drug in the cabinet has a page in the register and every page has a matching item in the cabinet.
A full count of every item matches the running balance, and the check is signed by two people.
Every register entry has two signatures from people who were on shift at that time.
Every administration in the register has a matching MAR or eMAR entry, and vice versa.
Every refusal, dropped dose and part dose has a destruction entry with a witness.
Every receipt matches a delivery note and every return matches a pharmacy signature.
Balance checks have been done at the frequency the policy sets.
Every discrepancy in the period was recorded, investigated, and where needed reported.
Staff who administer and witness have current training and competency records.

Record the findings and the actions. The audit trail matters as much as the count. Keep the audits, the actions and the incident records together so the story can be told on the day. The wider medicines audit is covered in the medication audit checklist for managers.

Reporting: CQC, the accountable officer and safeguarding

Every region in England has a Controlled Drugs Accountable Officer, based in NHS England, whose role includes receiving concerns and incident reports from care homes. Unexplained losses, suspected diversion and serious errors go to them, usually through an online form. The home should know who its CDAO is and how to reach them before it needs to.

CQC must be notified of incidents that meet the thresholds in the registration regulations, which includes events that cause harm and events involving the police. A controlled drugs incident is notifiable when it meets one of those criteria, for example a serious injury, an allegation of abuse or police involvement; not every discrepancy is. Report controlled drugs incidents to your regional NHS England CDAO through the CD reporting website, and know your police controlled drugs liaison officer. Safeguarding referrals to the local authority follow where a resident may have been harmed. The provider's own incident process runs alongside all of this, and the record should show every report made, with dates.

Training and competency

Every worker who administers or witnesses controlled drugs needs training that covers the schedules, the register, the cabinet, the procedure, the discrepancy process and the reporting route, followed by a competency assessment that includes a real or simulated administration with witness. The record of that training and assessment is kept, reviewed annually as NICE SC1 recommends, and shown to inspectors.

Agency and bank staff are the weak point. A home that lets an agency nurse administer controlled drugs on their first shift without checking their competency is taking a risk it does not need to take. The induction for any temporary worker includes the CD process, and the home's own staff witness until competency is confirmed.

Common mistakes

Adjusting the register to match the count. The discrepancy disappears and so does the chance to find out why it happened.
Witness signing afterwards. The second signature is collected at the end of the round, so nobody actually watched.
Keys in a drawer. Anyone in the medicines room can open the cabinet.
Register entries made after the dose. The balance is wrong between the dose and the entry, and interruptions mean some entries are never made.
Refused doses put back in the pack. The balance is right but the dose has been handled and is no longer fit to give.
Expired stock left in the cabinet. It inflates the count and confuses every check.
Patches not tracked. Nobody knows where the last one was or whether it was removed.
No CDAO contact. The home has an unexplained loss and does not know who to tell.

What good looks like on inspection day

The inspector asks to see the controlled drugs. The nurse in charge and a second worker take them to the cabinet, which is locked, fixed, and unmarked. The keys come from the nurse's pocket. The register is bound, current, and the last balance check was this morning with two signatures. The inspector picks oxycodone oral solution for one resident and asks for a count. Two workers count it and the volume matches the balance within the small tolerance the policy allows for liquids, and the policy is shown.

The inspector picks a register entry from last week and asks to see the MAR entry. It is there, with the same time, the same two names, and both were on the rota. They ask about the last discrepancy. The manager shows the record: a receipt entered as thirty when the note said twenty-eight, found at the next balance check, investigated the same day, corrected with an explained entry, and the receipt process changed so that two people now count on delivery. They ask who the CDAO is and the manager names them and shows the last report made.

That is what inspection-ready evidence looks like for controlled drugs. Not a perfect record, but a complete one, with two names on every line and an honest account of what went wrong and what changed.

Final conclusion

Controlled drugs are a small part of the medicines a care home manages and a large part of the risk. The legal floor is the safe custody cabinet, the register and lawful administration. The practice standard, set by NICE SC1 and expected by CQC, adds the witness, the regular balance check, the discrepancy investigation and the reporting route. Do those things every time, train every person who touches the cabinet, audit the register against the MAR every month, and report what you cannot explain. That is the whole discipline, and it is what keeps residents, staff and the home safe.

Frequently asked

Do care homes have to keep a controlled drugs register?

Yes for Schedule 2 drugs. CQC's guidance says that unless a person is looking after their own medicines, you must store Schedule 2 controlled drugs in a CD cupboard and record every receipt, administration, disposal and transfer in a CD register. That applies in homes with and without nursing. Schedule 3 drugs do not legally need register entries, but your policy may ask for them.

Does a controlled drug have to be witnessed in a care home?

CQC calls it good practice for two trained, competent staff to witness and sign when controlled drugs are received, given and disposed of. NICE SC1 recommends that the person giving the drug and a trained witness both sign the register. Plan your rota so a trained witness is always available, and say in your policy what happens if one is not.

Does Oramorph need to go in the CD register?

Morphine sulfate oral solution 10mg/5ml (Oramorph) is Schedule 5, so the law does not require a CD register entry or the CD cupboard. CQC still expects accurate records of receipt, administration and disposal, and many homes record it in the register by policy. Stronger morphine oral solutions are Schedule 2 and must go in the register. Check the strength on the label.

How are controlled drugs disposed of in a care home?

In a home without nursing, return them promptly to a community pharmacy, which denatures them; you do not need a T28 exemption. In a home with nursing, residents' own Schedule 2, 3 and 4 (Part I) drugs must be denatured under a T28 waste exemption, and Schedule 2 stock is destroyed in front of an authorised witness. Record every disposal in the register with a witness.

Can a care home keep the controlled drugs register electronically?

Yes. CQC confirms electronic registers are permitted instead of a bound book. Entries must be attributable to the person who made them, secure, and able to be audited, including corrections. The register must comply with best practice and be accessible and printable from the care home. Keep the register and the MAR reconciled, whichever format you use.

What should I do if the controlled drugs balance is wrong?

Recount with a different second person, check the register arithmetic, check the MAR for an unrecorded dose, and check receipts, returns and leave. If you find the cause, record it with a signed, dated correction. If not, report it to the manager, the regional NHS England CDAO and, where the criteria are met, CQC and the police. Never adjust the register to match the count.

Sources

Sources last checked: 28 October 2026.

Controlled drugsCD registerMedication

Controlled drugs in care homes: the register, the witness and the audit