Improving Controlled Drug knowledge and practice for Nursing Home staff. (2025)

Aneurin Bevan University Health Board

Project summary

Pharmacy technicians identified variations in Controlled Drug (CD) management during medicines audits of 47 nursing homes in ABUHB (2023–24). These issues led to errors in administration, storage, documentation, and disposal. Although advice was given during visits, recurring CD incidents suggested the information wasn’t always shared with staff.

To address this, we developed a training package to deliver accurate information directly to staff. Instead of visiting each home, we opted for a 30-minute webinar, scheduled twice on different weekdays after lunchtime to maximise attendance.

We reviewed audit data and sent out a questionnaire (via MS Forms) to identify key learning needs. The most problematic areas were CD register documentation, disposal processes, and stock receipt procedures. These, along with CD classification and legal requirements, formed the core of our training.

To support ongoing learning, we created resources for homes to use with new and agency staff. These included posters for medication rooms—one outlining the “life cycle of a controlled drug” and another with step-by-step disposal guidance. We also shared the webinar slides post-training.

Before the training, we issued a baseline questionnaire to assess existing knowledge. A follow-up questionnaire post-training showed improved scores, indicating increased knowledge. Post-training audits also revealed fewer CD incidents and better practices.

Feedback from staff and management was overwhelmingly positive. For some, the training reinforced prior knowledge; for others, it introduced new concepts. The training also positively influenced the culture and attitudes toward CD management, promoting safer and more efficient medicines handling for residents.