1. Policy Title

Medicines Management Policy – Governance of Medicines Use and Supply

2. Policy Reference

MED-GOV-001-SJ

3. Effective Date

01/01/2026

4. Review Date

01/01/2027

5. Version

1.0

6. Purpose

This Medicines Management Policy sets out the overarching governance framework for the safe, effective, and lawful use, prescribing, supply, storage, and monitoring of medicines, including Prescription Only Medicines (POMs).

The policy ensures compliance with:

• Human Medicines Regulations 2012

• Medicines and Healthcare products Regulatory Agency (MHRA) guidance

• Care Quality Commission (CQC) regulatory requirements and Key Lines of Enquiry (KLOEs)

• Professional standards for prescribing and medicines management

7. Scope

This policy applies to:

• All medicines prescribed, supplied, or managed by the organisation

• All clinical and non-clinical staff involved in medicines-related processes

• All service delivery models, including face-to-face, remote, and online services

8. Principles of Medicines Governance

The organisation is committed to ensuring that:

• Medicines are used only when clinically appropriate

• Patient safety is prioritised at all stages of the medicines pathway

• Prescribing decisions are independent, evidence-based, and free from commercial influence

• Medicines are supplied in accordance with legal and regulatory requirements

• Robust systems exist for monitoring, audit, and continuous improvement

9. Roles and Responsibilities

9.1 Accountable Officer / Registered Manager

• Overall responsibility for medicines governance

• Ensures systems are in place to meet regulatory requirements

• Oversees risk management and compliance

9.2 Clinical Lead

• Provides clinical oversight of prescribing and medicines use

• Ensures prescribing practices align with clinical guidelines

• Reviews incidents, audits, and non-compliance related to medicines

9.3 Prescribers

• Must be appropriately registered and authorised to prescribe

• Are responsible for clinical assessment, prescribing decisions, and documentation

• Must prescribe in the patient’s best interests and within scope of practice

9.4 Staff Involved in Medicines Supply

• Must follow SOPs relating to prescription verification, supply, and record keeping

• Must escalate concerns or deviations immediately

10. Prescribing and Supply of Medicines

10.1 Clinical Assessment and Prescribing

• All medicines, particularly POMs, require an appropriate clinical assessment prior to prescribing.

• Prescriptions may only be issued by authorised prescribers.

• Prescribing decisions must be documented and auditable.

10.2 Separation of Prescribing and Supply

• No medicine may be sold, supplied, or paid for without a valid prescription.

• Payment processes must not influence prescribing decisions.

10.3 Supply of Medicines

• Medicines must be supplied strictly in accordance with the prescription.

• Verification checks must be completed prior to supply.

11. Storage, Handling, and Security

• Medicines must be stored securely and in line with manufacturer guidance.

• Access to medicines must be restricted to authorised personnel.

• Temperature-controlled storage must be monitored and recorded where required.

12. Monitoring, Review, and Follow-Up

• Patients receiving medicines must be provided with appropriate information and follow-up arrangements.

• Monitoring requirements must be proportionate to the medicine prescribed.

• Systems must be in place to identify and respond to adverse effects.

13. Incident Reporting and Risk Management

• Medication errors, near misses, and adverse incidents must be reported in line with the Incident Management Policy.

• Incidents will be reviewed to identify learning and prevent recurrence.

• Serious incidents will be escalated appropriately.

14. Training and Competency

• All staff involved in medicines management must receive appropriate training.

• Training records must be maintained.

• Competency will be reviewed regularly.

15. Audit and Quality Assurance

• Medicines management processes will be subject to regular audit.

• Audit findings will be reviewed by the Clinical Lead.

• Actions will be implemented to support continuous improvement.

16. Record Keeping and Data Protection

• Accurate and complete records must be maintained for all medicines-related activities.

• Records must be stored securely and in accordance with GDPR and data protection legislation.

17. Linked Policies and SOPs

• Prescription Requirement Prior to Purchase of POMs SOP

• Prescribing Policy

• Online and Remote Prescribing SOP

• GLP-1 Prescribing SOP

• Weight Management Service SOP

• Incident Management Policy

• Consent and Capacity Policy

• Data Protection and GDPR Policy

18. Approval

Approved by: Caroline Balazs
Role: Lead Clinical Prescriber
Date: 01/01/2026