You can view all medicines management procedures by visiting the Policies and Procedures section of YourSpace and selecting Trust Wide (for aligned procedures) or the relevant former Division from the drop-down bar, and search with the relevant key word.

If a procedure cannot be found for a former Division, check that this has not been superseded by a Trust wide policy/procedure.

Former divisional procedures may also be found on:

  • SharePoint - Local / Secure / LD (now known as Secure Care and Mental Health Care)
  • SIRS - Community Division Services (now known as Community Care)

A list of Trust Wide procedure can be found on the Trust Wide Medicines Related Policies and Procedure tab below.

The policies and procedures listed below are available here.

Trust Wide procedures

MMP01 Safe Management of Controlled Drugs

MMP02 Safe Management of Unidentifiable and Suspected Illicit Substances

MMP03 Administration of Discretionary Medicines

MMP04 Overt and Covert Administration of Medicines in Food/Drink (Inpatients)

MMP05 Self Administration Scheme (SAM Scheme) - expected June 2023

MMP06 Transport, Transfer and Collection of Medicines - expected July 2023

MMP07 Medicines Reconciliation for Inpatients

MMP07a Medicines Reconciliation for Patients in the Community

MMP08 Administration of Medicines (inc. Self Administration of Medicines)

MMP09 Safe Use of Injectable Medicines

MMP10 Management of Community Prescriptions - expected Oct 2023

MMP11 Discharge Medicines Services (DMS)

MMP12 Use of Buprenorphine Injection (Buvidal)

MMP13 Non Medical Prescribing within the Anticoagulation Service

MMP14 Zuclopenthixol Acetate Guidelines and Procedure

MMP15 Administration of the Covid-19 and Seasonal Influenza Vaccination to Trust Inpatients

MMP16 Alcohol Detoxification  - expected July 2023

MMP17 Medicines Management in Special Schools

MMP18 Safe Prescribing of Established Methadone / Buprenorphine

MMP19 Transcribing of Medicines in Approved Services

MMP20 Management of Buccal Midazolam

MMP21 Rapid Tranquillisation - expected Dec 2023

MMP22 Take-Home Naloxone (Addictions Services) - expected June 2023

MMP23 Safe Use of Valproate - expected June 2023

MMP24 Safe Use of Clozapine - expected June 2023

MMP25 Patient's Own Drugs

MMP26 High Dose Antipsychotic Therapy (HDAT) - expected June 2023

MMP27 Management of Medicines Errors - expected July 2023

MMP28 Management of Thickening Agents in SALT Teams for Assessment

MMP29 Management of Anticoagulation Therapy - expected June 2023


MMP31 Transfer of Inpatient Medicines Records

MMP32 Medicines Management at Huyton CoRe and Cluster

MMP33 Ordering, Receipt and Storage of Medicines - expected July 2023

MMP34 Handling and Management of Covid-19 and Influenza Vaccines in and within the Trust

MMP35 Medicines Management in the IV Therapy Team - expected June 2023

MMP36 Medicines Management in GP Support Services

MMP37 Management of Anticipatory Medicines for End of Life Care in Community Childrens Nursing Team 

MMP38 Safe Use of Opioids

MMP39 Use of Unlicensed / Off-label Medicines

MMP40 Administration via a Nasogastric Tube - expected June 2023

MMP41 Medicines Management in Knowsley Treatment Rooms

MMP42 Prescribing (Inpatients)

MMP43 Safe Use of Potassium Permanganate

MMP44 Medicines Management at Wavertree Bungalow - expected May 2023

MMP45 Administration of Medicines by Health Care Support Workers

Trust Wide Policies

SD12 Safe and Secure Medicines

SD12A Covid-19 Vaccine Handling and Management

SD11 Rapid Tranquillisation

MCT08 Controlled Drugs

MM05 Non Medical Prescribing

SD50 Patient Group Directions

The procedures below are service specific and are applicable to the Medicines Management Team only:

The procedures below are applicable to the Medicines Management Department only and can be found on the S: drive > 'Pharmacy' Folder:

  • MMD03 Supply of Clozapine Procedure
  • MMD04 VBM Procedure
  • MMD06 Transport and Delivery of Medicines Procedure


EPMA User Guides / Procedures can be found here on the Medicines Management EPMA intranet page.

  • Risk assessment for insulin administration by HCSWs
    • To be completed by the register nurse/registered practitioner who will take responsibility for delegation of the task
  • Agreement form to consent to administration of insulin
    • The registered nurse/registered practitioner must obtain informed consent (see Appendix 3) to the delegation of the task from the person receiving care, or where that person does not have the capacity to give consent, the principles of the Mental Capacity Act (2005) should be followed as set out in the Consent to Treatment Policy (2015) and Mental Capacity Act (2005).

Training declaration forms related to Medicines Management internal training can be found here