CQC Highlights Care Home Controlled Drug Challenges in 2024 Annual Report
The Care Quality Commission (CQC) has published its annual controlled drugs oversight report for 2024, revealing key challenges facing care homes in managing controlled medications, particularly for end-of-life care.
The report, published on 15 July 2025, examines the CQC’s oversight activity under the Controlled Drugs (Supervision of Management and Use) Regulations 2013 and highlights findings from inspections and engagement with local controlled drug intelligence networks led by NHS England.
Among the primary issues identified in the report, the CQC specifically highlighted difficulties with “access to controlled drugs in care homes for end of life care” as a significant concern. This continues to be a persistent challenge for residential and nursing care providers seeking to ensure appropriate pain management and comfort care for dying residents.
The regulator also emphasised the critical importance of healthcare professionals working within their scope of practice – a particular concern for care homes where staff may not always have clear guidance on controlled drug administration boundaries.
The report identified concerning levels of fraudulent activity and diversion of controlled drugs by health and care professionals, as well as support staff. This included instances of people impersonating healthcare professionals to obtain controlled substances.
Of particular relevance to care settings, the CQC noted fraudulent prescriptions being produced within electronic systems in primary care to conceal theft, alongside ongoing fraud involving private prescriptions for controlled drugs in lower schedules.
NHS primary care services prescribed 74,160,671 controlled drug items in 2024, representing a slight increase of 0.4% compared with 2023. The report noted that overall prescribing levels across different schedules of controlled drugs remained stable.
Notable trends included increases in prescribing volumes of medicines licensed to treat ADHD, such as dexamfetamine, lisdexamfetamine and methylphenidate, and a continued increase in testosterone prescribing.
Conversely, there were reductions in prescribing of several medications commonly used in care settings, including pholcodine, pethidine, fentanyl, diamorphine, zopiclone and zolpidem.
The report highlighted significant growth in non-medical prescribing, with pharmacist prescribing continuing to expand and accounting for over half of all non-medical prescribing. Paramedic prescribing increased dramatically by 704% in 2024 compared with 2023, following legislative changes at the end of 2023 that permitted paramedic independent prescribers to prescribe a range of controlled drugs.
Cannabis-based products for medicinal use (CBPMs), which are Schedule 2 controlled drugs, continue to be prescribed almost exclusively in the independent sector. The most recent data showed a 130% increase in unlicensed CBPM prescribing in independent services between 2022/23 and 2023/24.
The report also flagged impending changes to NHS England and the regional and national controlled drugs oversight function, which may affect how care homes interact with oversight bodies in future.
The CQC noted the ongoing need to improve cross-border prescribing datasets on controlled drugs, which could impact care homes operating across different regions or accepting residents from various areas.
The report included themes identified from a review of Prevention of Future Death Reports, shared to highlight the risks associated with controlled drugs across healthcare settings, including care homes.
The CQC has made recommendations in the report to raise awareness and address the specific issues identified during 2024, with particular attention to ensuring appropriate access to controlled drugs for end-of-life care while maintaining robust security and governance arrangements.
