Practice Controlled Drugs (CD) Self-Assessment and Declaration Form

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Closes 16 Aug 2021

Practice CD Self-Assessment and Declaration Form

Please answer all questions regarding the Practice CDα Self-Assessment and Declaration Form and submit before the 14th May 2021.

Refer to the cover letter for links to supporting guidance as necessary.

α - Applies to CDs of ALL schedules (i.e. Schedules 2-5)

Self Assessment

Please enter your practice details
Procedures:

1. Do you have written standard operating procedures or policies (SOP) covering the complete area of handling and management of CDs, appropriate to the activities carried out within your practice, and as required by the Accountable Officer regulations, i.e:

  • Access to CDs  (including use of HS21S by GPs and locums)
  • Storage and transportation
  • Security
  • Disposal and destruction (including any patient returns)
  • Who to alert if complications arise
  • Record keeping
  • Prescribing, supply, administration and clinical monitoring of CDs

This applies to all CDs Schedule   2-5 and is a legal requirement.

(Required)
2. Do you have a practice procedure for identifying, dealing with and learning from significant events** involving CDs?

**Significant event includes any incident where a patient is harmed or nearly harmed and includes ‘near misses’, when things almost go wrong.

(Required)
3. Do you have appropriate procedures for the initial and continuing training and development of all staff who are involved in the prescribing, handling, supply, storage, administration and disposal of CDs?
(Required)
4. Do you have assurance that all CD prescribers (including regular locums and non-medical prescribers) are aware of the practice CD SOP and trained as necessary?
(Required)
5. Do you have a prescription security protocol?
(Required)
6. Do you have a process where individual stocks of CDs (and CD register for Sch 2 CDs) are ordered and held by each GP who requires these for their clinical use?
(Required)
7 a) Do you have a process where central stocks of CDs (e.g. held in treatment room) are not permitted. This applies to all Schedules and includes codeine and benzodiazepines / Z drugs (Exceptions: rectal diazepam/buccal midazolam for emergency use).
(Required)
7 b) Are rectal diazepam or buccal midazolam for emergency use held centrally?
(Required)
8. Are yellow copies of stock orders retained for 2 years?
(Required)
9. Do you have a process for expiry date checks on CD stock?
(Required)
Complaints/Concerns/Incidents regarding prescribing, supply and/or administration of Controlled Drugs

1. Have there been any patient or carer complaints* involving CDs within the last two years?

*Includes complaints about prescribing inappropriate doses and/or appropriate medicines.

(Required)
2. Do you have a process for highlighting concerns about particular patients’ use of CDs, (including high dose oral morphine equivalence)? E.g. discussion with GP colleagues and HSCB advisers
(Required)
3. Have there been any concerns expressed by colleagues, police, drugs misuse services or others about unusual, excessive or inappropriate use of CDs by patients?
(Required)
4. Have GPs identified any discrepancies between CD register running balances and actual CDs stored in the last 2 years?
(Required)
5. Have there been any other significant events** involving CDs?

**Significant event includes any incident where a patient is harmed or nearly harmed and includes ‘near misses’, when things almost go wrong.

(Required)
Prescribing

1. Are there any special factors which influence the prescribing or use of CDs by the Practice? (For example, patient demographics, involvement with Nursing Homes/Hospices, prescribing for addicts.)

(Required)
2. Are there any restrictions on the possession, administration or prescribing of controlled drugs on any of the healthcare professionals (HCP) in your practice?
(Required)
3. Are all CDs reviewed regularly in line with latest guidance and best practice to ensure prescribing is safe and appropriate?
(Required)
4. Are all acute prescription requests and repeat re-authorisations for CDs actioned by a prescriber or approved clinician?
(Required)
5. Are permissions set so that only clinical staff are authorized to delete prescriptions which have already been issued from the prescription history?
(Required)
6. To check for potential fraudulent activity does the practice carry out a regular review of prescriptions which have been issued and subsequently deleted from the prescription history*?

*Quarterly review is recommended and focus should be on CDs and other medicines liable to abuse/misuse

(Required)
7. Are all CD prescriptions (Schedule 2-4) limited to 30 day supply? (Note: this includes less obvious CDs such as phenobarbitone and testosterone)
(Required)
8. Are controlled release CDs prescribed by brand name in line with HSCB Generic Exceptions List?

Click here for the HSCB Generic Exceptions List

(Required)
9. (a) Do you prescribe CDs to addicts as part of a substance misuse service?
(Required)

(b) Do you prescribe CDs outside of this scheme to patients whom you suspect may have addictions problems? 

(Required)
10. If you need to carry out private/non-HS work:
  1. Are private prescriptions used where appropriate for patients (e.g. the use of a PCD1 form for Schedule 2 and 3 CDs and  headed notepaper for Schedule 4 and 5) ?
(Required)

2. Are CDs required for stock ordered on private forms (e.g. CDRF1 form for Schedule 2 and 3 CDs and headed notepaper for Schedule 4 and 5) ?

(Required)
Self-Assessment - Additional information