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Safe Collection and Handling of Prescriptions Policy

1. Purpose

The purpose of this policy is to ensure that the collection, ordering, receipt, transport, handover, recording and, where agreed in the personal plan, support with medicines is carried out safely, lawfully and in a person-centred way within {{org_field_name}}’s domiciliary support service. This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 as amended, including Regulation 58 on medicines, the Welsh Government statutory guidance for care home and domiciliary support services last updated in March 2024, the Human Medicines Regulations 2012, the Medicines Act 1968, the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001, the Mental Capacity Act 2005, the Equality Act 2010, data protection legislation, and NICE Guideline NG67, Managing medicines for adults receiving social care in the community.

As a home care provider, we recognise that medication management is a critical aspect of care. Our organisation is committed to reducing medication risks through proper prescription handling, secure transport, accurate documentation, and staff training. This policy outlines clear procedures that staff must follow to ensure service users receive the correct medications at the right time while maintaining their safety, dignity, and independence.

{{org_field_name}} will not take responsibility for any aspect of a service user’s medicines unless this has been assessed as necessary, agreed with the service user and/or their representative where appropriate, and recorded in the service user’s personal plan. The level of medicines support provided will be the least restrictive option and will promote the service user’s independence, choice, dignity and control wherever safe and practicable.

2. Scope

This policy applies to:

• All staff members, including care workers, team leaders, and managers who are responsible for supporting service users with their prescriptions.
• Service users who require assistance in collecting, handling, and managing their prescriptions.
• Pharmacies and healthcare professionals involved in the prescription process.
• Family members and representatives who play a role in medication management.

It covers all aspects of prescription handling, including:

• The collection of prescriptions from pharmacies.
• The secure transport and storage of medications.
• Ensuring safe handover to service users.
• Handling controlled drugs safely and legally.
• Preventing medication errors, fraud, and misuse.
• Staff training and responsibilities in prescription management.

2.1 Relationship with the Medication Management and Administration Policy

This policy must be read alongside the Medication Management and Administration Policy (DCW21). This policy focuses on the safe collection, ordering, receipt, transport, handover and documentation of prescriptions and medicines. Where staff are required to administer medicines, prompt medicines, apply creams, support with inhalers, support with “when required” medicines, support time-sensitive medicines, support over-the-counter medicines, or undertake any delegated health-related medicines task, staff must also follow DCW21, the service user’s personal plan, the medicines administration record, and any written instructions from the prescriber, pharmacist or relevant health professional.

3. Assessment, Consent and Personal Plan Requirements

Before {{org_field_name}} agrees to collect, order, transport, store, dispose of, administer or otherwise support a service user with medicines, the service user’s medicines support needs must be assessed as part of the provider assessment and recorded in the service user’s personal plan. The assessment must consider what the service user can do independently, what support is required, any risks linked to medicines, mental capacity, consent, communication needs, allergies, time-sensitive medicines, “when required” medicines, controlled drugs, storage needs, and the roles of family members, representatives, pharmacists, GPs, community nurses or other professionals.

The personal plan must clearly state who is responsible for ordering, collecting, transporting, storing, administering, disposing of and recording medicines. Staff must only provide the medicines support that has been agreed and documented in the personal plan. Where responsibility is shared with family members, representatives or another provider, the arrangements must be clearly recorded to avoid duplication, missed doses, errors or confusion.

The service user must be encouraged and supported to manage their own medicines wherever they are willing and able to do so safely. Staff must not take over medicines tasks simply for convenience. Any restriction on the service user’s access to their own medicines must be based on an individual risk assessment, agreed with the service user and/or their lawful representative where appropriate, and recorded in the personal plan.

4. Safe Collection and Handling Procedures

4.1 Prescription Requests, Ordering and Re-ordering

Responsibility for ordering medicines will remain with the service user and/or their family or representative unless the provider assessment and personal plan state that {{org_field_name}} is responsible for ordering or supporting the ordering of medicines.

Where {{org_field_name}} is responsible for ordering or re-ordering medicines, authorised and competent staff must:

• check the personal plan, current medicines administration record, medication labels, and any written instructions from the prescriber or pharmacist before ordering;
• order medicines in sufficient time to maintain continuity of supply and reduce the risk of missed doses;
• record the date the medicine was ordered, the name, strength, form and quantity of the medicine ordered, who placed the order, and the pharmacy or GP surgery contacted;
• check whether there have been any recent hospital admissions, GP appointments, medication reviews, discontinued medicines, dose changes or new medicines;
• confirm who will collect or receive the medicines and when;
• check the medicines supplied against the medicines ordered and report any discrepancy immediately to the pharmacy, GP surgery where appropriate, and the Registered Manager;
• ensure that staff have enough allocated time to check what is required, place the order, collect or receive medicines, and check the supply safely.

Staff must not delegate ordering responsibilities to the supplying pharmacy, another provider or a family member unless this has been requested and agreed by the service user and/or their representative, and the arrangement is recorded in the personal plan.

4.2 Collection of Prescriptions

Only authorised staff members who have undergone medication management training are permitted to collect prescriptions. When collecting, staff must:

• Present appropriate identification and authorisation from the organisation.
• Check the supplied medicines against the order, prescription token where available, dispensing label, medicines administration record where applicable, and any pharmacy paperwork. Staff must check the service user’s name, date of birth where available, medicine name, strength, form, dose instructions, quantity supplied, expiry date where visible, storage requirements, and whether a patient information leaflet has been supplied.
• Check for any special handling instructions, including refrigeration or controlled drug requirements.
• Ensure that any additional medication information leaflets provided by the pharmacy are collected and passed to the service user.

If a prescription collection involves controlled drugs (CDs), additional legal documentation may be required, and staff must sign for receipt at the pharmacy. Any discrepancies must be reported to the Registered Manager immediately.

Staff must not accept or collect medicines where the identity of the service user is unclear, the medicine appears to be for another person, the packaging appears damaged or tampered with, the label is illegible, the medicine supplied does not match the order or MAR, or the instructions are unclear. In these circumstances staff must seek advice from the pharmacist before leaving the pharmacy wherever possible and must inform the Registered Manager.

Staff must not make clinical decisions about whether a medicine is suitable, whether a dose should be changed, or whether a medicine should be stopped. Clinical queries must be referred to the pharmacist, prescriber, GP, community nurse or other appropriate healthcare professional.

4.3 Safe Transport and Storage of Medication

Medicines must be transported directly and safely to the service user’s home unless an alternative arrangement has been risk assessed, agreed and recorded. Where {{org_field_name}} is responsible for transporting medicines, staff must:

• use a clean, secure and discreet container or bag;
• keep medicines in their original pharmacy packaging;
• keep medicines out of sight during transport;
• not leave medicines unattended in vehicles, public spaces or staff homes;
• take reasonable steps to maintain any required storage conditions, including refrigeration requirements;
• deliver medicines as soon as practicable to the service user, their representative, or another person identified in the personal plan;
• report any delay, loss, damage, suspected tampering or temperature-storage concern immediately to the Registered Manager and seek pharmacy advice before the medicine is used.

For service users who require assistance with medication storage, staff should ensure that:

• Medication is stored in a cool, dry place away from children, pets, or heat sources.
• Any fridge-stored medication is placed in a clearly labelled section of the fridge.
• The service user understands where their medication is kept and how to access it.

Medicines in the service user’s home remain the property and responsibility of the service user unless the personal plan states otherwise. Staff must promote the service user’s independence and must not restrict access to medicines unless this is required by an individual risk assessment. Where there is a risk from unsecured medicines, including risk of accidental overdose, confusion, misuse, diversion, children or visitors accessing medicines, declining or fluctuating mental capacity, or unsafe storage conditions, the Registered Manager must review the risk assessment and agree safe storage arrangements with the service user and/or their representative. This may include use of a lockable medicines box or cupboard, where appropriate.

Fridge medicines must be stored in accordance with pharmacy instructions. Staff must not place medicines in a fridge unless this is required by the label or pharmacy advice. Where staff are responsible for monitoring fridge storage, the required checks and frequency must be recorded in the personal plan.

4.4 Handover, Receipt and Documentation

Every collection and delivery of medicines must be recorded. The record must include:

• service user’s full name;
• date and time of collection;
• pharmacy or dispensing location;
• name, strength, form and quantity of each medicine collected where this information is available;
• name and signature of the staff member collecting;
• date and time of delivery to the service user’s home;
• name and signature of the person receiving the medicines, where practicable;
• any discrepancies, damaged packaging, missing medicines, unclear instructions, storage concerns, or medicines not collected;
• action taken and who was informed.

Where medicines support is provided, staff must ensure that the MAR or other approved medicines record is accurate and available before any medicine is administered or supported. Staff must record medicines support on every occasion and for each individual medicine, including whether the medicine was administered, prompted, declined, not available, withheld on professional advice, or not required.

Staff must not amend a MAR unless they have been trained and assessed as competent to do so and the change is supported by written confirmation from the prescriber, pharmacist or other authorised healthcare professional. Any handwritten MAR amendment must be dated, signed, and checked by a second competent person wherever possible.

If a service user declines medicine, staff must record the refusal, respect the service user’s right to decline, and follow the escalation procedure in the personal plan. Staff must seek advice where refusal creates a risk, involves time-sensitive medicines, occurs repeatedly, or is linked to confusion, distress, side effects, swallowing difficulty, pain, or possible lack of mental capacity.

4.5 Controlled Drugs

Controlled drugs must be handled with additional safeguards because of the risk of harm, misuse, diversion and legal control. Staff must only collect, transport, record, store, administer or return controlled drugs where this is included in the service user’s personal plan and the staff member has been trained and assessed as competent.

When collecting or receiving controlled drugs, staff must check the service user’s name, medicine name, strength, form, dose instructions and quantity supplied against the pharmacy label, order record, MAR or other approved record. Staff must sign any pharmacy collection record where required and must record the collection and delivery in the service’s medicines collection record.

Where {{org_field_name}} is responsible for supporting controlled drug administration or stock monitoring, a controlled drug record must be maintained. The record must include the date, time, medicine name, strength, quantity received, quantity administered where applicable, remaining balance where required, name and signature of the staff member, and any witness signature where required by the risk assessment or local procedure.

Controlled drugs must be stored in the service user’s home in accordance with the individual risk assessment and pharmacy advice. Where secure storage is required, this must be agreed with the service user and/or their representative and recorded in the personal plan.

Any discrepancy, missing controlled drug, suspected diversion, suspected misuse, unexplained stock difference, damaged packaging or recording error must be reported immediately to the Registered Manager. The Registered Manager must seek pharmacy or prescriber advice, consider whether safeguarding action is required, and follow the incident and notification procedure where applicable.

4.6 Over-the-Counter Medicines, Homely Remedies and Supplements

Staff must not purchase, recommend, administer or support the use of over-the-counter medicines, herbal remedies, supplements or homely remedies unless this has been agreed in the personal plan and advice has been obtained from a pharmacist, prescriber or other appropriate healthcare professional where required. The name, strength, dose, reason for use, maximum dose, duration of use, risks, and person authorising use must be recorded.

Staff must report any concern that an over-the-counter medicine, supplement or remedy may interact with prescribed medicines or may be unsafe for the service user.

4.7 Time-Sensitive and “When Required” Medicines

Where a service user has time-sensitive medicines, such as medicines for Parkinson’s disease, epilepsy, diabetes, pain relief, antibiotics, anticoagulants, or any other medicine where delay or omission may cause harm, the personal plan must clearly state the required administration or support times, the permitted time window, and the action staff must take if a visit is delayed or a dose is missed.

Where a service user has “when required” medicines, the personal plan or PRN protocol must state what the medicine is for, the dose, minimum interval between doses, maximum dose in 24 hours, signs or symptoms that indicate the medicine may be needed, how the service user communicates need or pain, expected outcome, side effects to monitor, and when to seek medical advice.

4.8 Medication Changes and Verbal Instructions

Staff must not act on unclear or informal medication changes. Medication changes should be supported by written instructions from the prescriber, pharmacist or other authorised healthcare professional.

Where a medication change is given verbally to avoid delay in treatment, the staff member must record the name and role of the person giving the instruction, the date and time of the instruction, the exact medicine name including spelling, strength, dose, route, frequency, start date, stop date where applicable, and the reason for the change where provided. The staff member must read the instruction back to the prescriber or authorised professional to confirm accuracy and must request written confirmation as soon as possible. The Registered Manager or delegated senior staff member must be informed before the change is implemented wherever practicable.

4.9 Covert Administration

Staff must never give medicines covertly unless there is clear authorisation in the personal plan and the process complies with the Mental Capacity Act 2005. Covert administration may only be considered where the service user lacks capacity to make the specific decision about the medicine, a best interests decision has been made, less restrictive options have been considered, and written instructions are available for staff.

The decision-making process must involve appropriate professionals, including the prescriber and pharmacist, and must record who was involved, the reason covert administration is necessary, how the medicine will be given safely, how risks will be managed, what staff training is required, and when the decision will be reviewed. Care workers must not independently decide to give medicines covertly.

4.10 Disposal and Return of Medicines

Responsibility for disposing of unwanted, damaged, expired, discontinued or part-used medicines will remain with the service user and/or their family or representative unless the personal plan states that {{org_field_name}} will support this task.

Where staff support the return or disposal of medicines, the service user’s consent must be obtained where they have capacity to consent. Medicines should normally be returned to a community pharmacy for safe disposal. Staff must not dispose of medicines in household waste, sinks or toilets.

A record must be made of any medicine returned for disposal. The record must include the service user’s name, medicine name, strength and quantity where known, reason for return, date returned, name of the staff member returning it, and the name of the pharmacy. Controlled drugs, sharps, needles, syringes and medicines requiring special disposal must be managed in line with pharmacy advice and the Medication Management and Administration Policy.

5. Preventing Medication Errors and Fraud

To minimise medication errors, staff must:

• Cross-check prescriptions against care plans before collection.
• Report any missing or incorrect medication immediately.
• Follow a clear chain of custody when handling medication to prevent theft or fraud.
• Be aware of signs of medication misuse or overuse and report concerns to the Safeguarding Lead ({{org_field_safeguarding_lead_name}}).

If a medication error, near miss, discrepancy, missed dose, delayed dose, incorrect collection, incorrect supply, refusal, suspected adverse effect, suspected misuse, suspected diversion, stockpiling concern, missing medicine, damaged medicine, or unclear instruction occurs, staff must:

• ensure the immediate safety and well-being of the service user;
• seek urgent medical advice where there is any risk of harm;
• contact the pharmacist, GP, prescriber, NHS 111, emergency services or other relevant health professional as appropriate;
• inform the Registered Manager or on-call manager immediately;
• record the facts clearly, including what happened, when, who was involved, what advice was sought, and what action was taken;
• complete an incident report before the end of the shift or as soon as practicable;
• inform the service user and/or representative in an open and honest way, unless doing so would create a safeguarding risk or be inconsistent with the service user’s well-being;
• consider whether a safeguarding referral, CIW notification, commissioner notification, or professional referral is required.

The Registered Manager must review medication incidents and near misses to identify trends, learning, staff training needs, care plan changes, pharmacy issues, communication failures or system improvements. Learning from medicines incidents must be shared with staff and included in quality assurance and audit processes.

6. Audit, Monitoring and Quality Assurance

The Registered Manager must ensure regular audits of prescription collection, medicines ordering, receipt, handover, MAR records, controlled drug records, disposal records, incident reports and staff competency records. Audits must check whether medicines records are accurate, complete, up to date and consistent with the service user’s personal plan.

Any audit findings must be risk assessed and acted upon promptly. Actions may include updating the personal plan, contacting the GP or pharmacy, retraining staff, competency reassessment, supervision, disciplinary action, safeguarding referral, or changes to the medicines procedure.

The Responsible Individual must ensure there are effective systems for oversight of medicines management and that themes from medicines incidents, audits, complaints and safeguarding concerns are considered as part of the quality-of-care review.

7. Staff Training and Responsibilities

All staff involved in prescription collection, medicines ordering, transport, handover, recording, storage, administration or any other medicines support must complete training appropriate to their role and must be assessed as competent before undertaking the task. Competency assessment must include direct observation where the task involves administration or practical medicines support.

Training and competency must cover, where relevant:

• the organisation’s Medication Management and Administration Policy and this policy;
• the 6 rights of medicines administration: right person, right medicine, right route, right dose, right time and the person’s right to decline;
• prescription ordering, collection, transport, handover and documentation;
• MAR records and safe record keeping;
• controlled drugs;
• time-sensitive medicines and “when required” medicines;
• over-the-counter medicines;
• safe storage and disposal;
• medication errors, near misses and escalation;
• safeguarding concerns linked to medicines, including misuse, diversion, stockpiling and financial abuse;
• mental capacity, consent and covert administration;
• confidentiality and data protection;
• delegated healthcare tasks where applicable.

Staff competency must be reviewed at least annually, sooner if there is a medicines incident, concern about practice, change in role, change in medicines responsibilities, return from extended absence, or introduction of a new medicines task.

Staff must adhere to professional boundaries and never:

• Accept financial incentives or gifts in exchange for handling prescriptions.
• Collect medication for non-service users.
• Alter, forge, or dispose of prescriptions without authorisation.

• recommend that a service user starts, stops or changes a medicine unless this advice has come from an appropriate healthcare professional;
• remove medicines from original packaging unless this is part of agreed administration support and the medicine is being administered immediately;
• leave medicines out for the service user to take later unless this has been risk assessed, agreed and recorded in the personal plan;
• administer or support a medicine where the label, MAR or instructions are unclear;
• administer medicines covertly without a lawful best-interests process and written authorisation;
• use another service user’s medicines, even if the medicine appears to be the same;
• transport medicines for non-service users or outside the agreed care arrangement.

Failure to follow this policy may result in disciplinary action in accordance with the Disciplinary and Grievance Policy (DCW31).

8. Related Policies

This policy should be read alongside:

• Medication Management and Administration Policy (DCW21)
• Safeguarding Adults from Abuse and Improper Treatment Policy (DCW13)
• Risk Management and Assessment Policy (DCW18)
• Confidentiality and Data Protection Policy (DCW34)
• Whistleblowing (Speaking Up) Policy (DCW29)

9. Policy Review

This policy will be reviewed at least annually, or sooner if there are changes in legislation, Welsh Government statutory guidance, CIW requirements, NICE guidance, local safeguarding procedures, commissioner requirements, pharmacy arrangements, internal audit findings, medication incidents, safeguarding concerns, complaints, or changes to the service’s statement of purpose. The Registered Manager is responsible for implementing this policy in day-to-day practice. The Responsible Individual is responsible for ensuring suitable arrangements are in place to keep the policy under review and to monitor compliance through audit and quality assurance.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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