Care homes registered with the Commission for Social Care Inspection (CSCI) must provide a report of serious incidents to CSCI. The CSCI retains these reports in the service record and the information is used during a key inspection process when the care service star rating and inspection frequency is determined. CSCI does not inform any other agency and the content of serious incident notifications is not published.
CSCI does not receive notification if a controlled drug error was made by the general practitioner who prescribed the controlled drug or by the community pharmacist who supplied the controlled drug. When errors relating to prescribing and supply of medicines occur within the national health service, primary care trusts are encouraged to have a procedure to report the errors to the National Patient Safety Agency (NPSA). But there is no current mechanism for social care services to make similar reports to NPSA about medicine administration errors.
In general, a patient will be assessed by their prescriber before a prescription, including one for a controlled drug, is issued. However, there is no requirement in regulation for the patient to be examined. The decision as to whether an examination is required is a clinical one made by the prescriber.