From our analysis of prescribing data, feedback from controlled drug local intelligence networks, and our wider inspection and regulatory work, we make the following recommendations to drive improvement in the safer management of controlled drugs:

• Make sure your governance processes are up-to-date and fit for purpose. In the last 2 years we have made recommendations around the importance of governance in the context of controlled drugs. We continue to monitor the progress, but still find areas that need to improve across health and social care. This is particularly the case where there are complex commissioning arrangements for services.
  
  For example, where several providers are involved in delivering a person's care, it's important to have clear roles and responsibilities in relation to controlled drugs, such as reporting incidents. All parties involved must understand and agree these so that people receive safe care.
  
  Local intelligence networks can provide examples of good governance processes, which providers can adopt and tailor to their own services. You can also use our self-assessment tools for primary and secondary care organisations.
• Make sure prescribing at transfer of care is completed safely. Clinicians must have the relevant medical and medication history before prescribing controlled drugs to patients. Private prescribing services should request these details from a person's NHS GP before issuing prescriptions, and NHS GP services should supply these details in an appropriate way when asked. See prescribing guidance from the General Medical Council.
• Know the identity of your local controlled drugs accountable officer (CDAO) and police controlled drug liaison officer CLDO. Any organisation with a responsibility around controlled drugs must have these details and know how to report controlled drugs incidents. CDAOs and CDLOs are important partners and can provide help, support and advice on a wide range of controlled drugs issues, as well as for reporting incidents.
  
  The Association of Police Controlled Drug Liaison Officers website enables you to check the up-to-date contact details for your local CDLO and details of your local NHSE CDAO are on our CDAO register.
• Work collaboratively to improve the prescribing, managing and monitoring of controlled drugs. We have already seen examples of how better collaboration and partnership working as part of a local system can result in improved safety and better outcomes for people.
• Make sure you have a valid Home Office controlled drugs licence if you are required to have one. This involves forward planning to check when licences are due to expire, or when a new licence is needed. You must allocate enough time to complete this process, otherwise it will affect your ability to provide care. The Home Office provides further advice.

We will continue to monitor progress against these recommendations.