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If a procedure cannot be found for a former Division, check that this has not been superseded by a Trust wide policy/procedure.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



MMP07 Medicines Reconciliation for Inpatients


MMP09 Safe Use of Injectable Medicines


MMP11 Discharge Medicines Services (DMS)

MMP12 Use of Buprenorphine Injection (Buvidal)

MMP13 Non Medical Prescribing within the Anticoagulation Service


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




MMP19 Transcribing of Medicines in Approved Services

MMP20 Management of Buccal Midazolam








MMP28 Management of Thickening Agents in SALT Teams for Assessment



MMP31 Transfer of Inpatient Medicines Records



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

MMP43 Safe Use of Potassium Permanganate

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

SD36 Use of Unlicensed & Off-label Medicines

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:

  • MMD06 Transport and Delivery of Medicines Procedure


  • 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).

The following flowcharts provide guidance to staff ordering medicines from Rowlands Pharmacy (Hollins Park):

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