Covert medication policy

What covert administration is, and the rules behind the policy

Covert administration of medicines means giving a person a medicine in a disguised form without their knowledge. The Care Quality Commission (CQC) guidance page Covert administration of medicines defines it: “Covert administration is when medicines are administered in a disguised format. Medicines could be hidden in food, drink or given through a feeding tube without the knowledge or consent of the person receiving them.” It is covert only when the person does not know they are taking a medicine. Mixing a tablet into jam for someone who knows it is there, because it is easier to swallow, is not covert administration, although crushing it may still need the prescriber's agreement (section 04).

No Act or regulation uses the phrase “covert medication policy”. The duties behind it are in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: regulation 12(2)(g) requires “the proper and safe management of medicines”; regulation 17(2)(c) requires an accurate, complete and contemporaneous record of the care and treatment provided “and of decisions taken in relation to the care and treatment provided”; and regulation 11(3) says that where a service user aged 16 or over cannot consent because they lack capacity, “the registered person must act in accordance with the 2005 Act”, the Mental Capacity Act 2005. The national guidance then puts the covert process inside the medicines policy:

• CQC. “The medicine policy should include a clear explanation of your covert medicines process. The policy should be specific and up to date. Your staff must read, understand and follow the policy.”
• Care homes. Recommendation 1.1.2 of the National Institute for Health and Care Excellence (NICE) guideline Managing medicines in care homes (SC1) says a care home medicines policy “should include written processes for” care home staff giving medicines to residents without their knowledge (covert administration).
• Home care and supported living. Recommendation 1.1.2 of NICE guideline Managing medicines for adults receiving social care in the community (NG67) is softer: a social care provider with responsibilities for medicines support should have a documented medicines policy whose content “will depend on the responsibilities of the social care provider, but it is likely to include processes for” covert administration.
• Across a local area. SC1 recommendation 1.15.4 says commissioners and providers of care home services “should consider establishing a wider policy on the covert administration of medicines across several health and social care organisations”, so check whether your area already has one before writing your own.

A separate, standalone covert medication policy is perfectly acceptable, but it is not a legal requirement; what the guidance asks is that the medicines policy explains the process, and that staff follow it.

This guide is about adults in CQC-registered care homes and home care services in England. The Mental Capacity Act also applies in Wales, but CQC and NICE's social care guidance do not set the standards there; Welsh providers should follow Care Inspectorate Wales requirements. In Scotland, medical treatment for an adult who lacks capacity follows Part 5 of the Adults with Incapacity (Scotland) Act 2000, and the Mental Welfare Commission's Covert medication: good practice guide is the reference. Some NHS covert medication pathways online are Scottish, so check which country a document was written for.

What a covert medication policy should contain

Built from CQC's page, NICE SC1 recommendation 1.15.3, NICE NG67 recommendation 1.8.3 and its definition of medicines-related problems, and NICE quality standard QS85 statement 6, the covert section of a medicines policy should cover:

1. Trying other options first. CQC: “Covert administration must be the least restrictive option after trying all other options. Carry out a functional assessment to try to understand why the person is refusing to take their medicines. You should also consider alternative methods of administration.” NG67 adds “seeking advice from the prescriber about other options, for example, whether the medicine could be stopped”.
2. A capacity assessment for the specific decision. NG67 1.8.3: “assessing a person's mental capacity to make a specific decision about their medicines”. Covert administration is considered only for a person assessed as lacking capacity to make that decision.
3. A best-interests meeting, and who attends. SC1 1.15.3 names care home staff, “the health professional prescribing the medicine(s), pharmacist and family member or advocate”. CQC says the meeting can be held remotely, “but you should keep clear records of who was involved and what was agreed”. NICE quality standard QS85 adds someone who can communicate the person's views, such as a family member, friend or independent mental capacity advocate (IMCA).
4. Who is responsible for decisions. NG67 says the process should clearly define “who should be involved in, and responsible for, decision-making”.
5. Recording the decision. SC1: “recording the reasons for presuming mental incapacity and the proposed management plan”. NG67 adds “agreeing where records of the decision are kept and who has access”.
6. How each medicine will be given. NG67: “planning how medicines will be given covertly, for example, by seeking advice from a pharmacist”, including the prescriber's authorisation when a tablet is crushed or a capsule opened (section 04).
7. Authorisation in the care plan. NG67: “providing authorisation and clear instructions for care workers in the provider's care plan”.
8. Training and competence. NG67: “ensuring care workers are trained and assessed as competent to give the medicine covertly”.
9. Review. When the decision will be reviewed, and what triggers an earlier review (section 05).
10. Fluctuating capacity. CQC: “If a person has fluctuating capacity, the service should have a covert plan in place. You must only use the plan when the person lacks capacity.”
11. Refused food or drink. What staff do if the person refuses the food or drink the medicine is in, which CQC lists among the contents of the care plan.
12. Misuse. NG67 counts “restraint or covert administration that has been used inappropriately” among medicines-related problems, so the policy should say how staff raise it, alongside the provider's safeguarding procedure.

Two things a good policy says plainly. First, the decision is never one person's: CQC says it “must be a multi-disciplinary team decision” and “the decision must not be taken alone”. Second, it is never a blanket permission: the need is identified for each medicine, and again whenever a medicine is added or a dose changes.

The decision: capacity and best interests, medicine by medicine

A person who can decide about a medicine can refuse it. CQC says a person with capacity has the right to refuse “even if that refusal appears ill-judged to staff or family members who are caring for them”, and NICE SC1 recommendation 1.15.1 says practitioners should not give medicines covertly to a resident who has capacity to make decisions about their treatment and care. The NHS Specialist Pharmacy Service, in Covert administration of medicines: legal issues, puts the consequence directly: overriding a capable person's refusal “would be a civil wrong and constitutes trespass to the person”.

CQC says covert administration is only likely to be necessary or appropriate where a person actively refuses their medicine, is assessed under the Mental Capacity Act 2005 as not having the capacity to understand the consequences of refusing, and the medicine is “deemed essential to the person's health and wellbeing”. The principles in section 1 of the Mental Capacity Act 2005 apply to every step:

• a person must be assumed to have capacity unless it is established that they lack it;
• a person is not to be treated as unable to decide unless all practicable steps to help them have been taken without success;
• “A person is not to be treated as unable to make a decision merely because he makes an unwise decision” (section 1(4));
• the decision must be made in the person's best interests (section 1(5));
• regard must be had to whether the purpose “can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action” (section 1(6)).

Capacity is decision-specific. Under sections 2 and 3, a person lacks capacity if, because of an impairment of, or a disturbance in the functioning of, the mind or brain, they cannot understand, retain, or use or weigh the information about this medicine, or communicate a decision. A person may be able to decide about a painkiller and not about an anticoagulant. The mental capacity assessment records guide covers the two-stage test and what the record shows.

Who decides. The Mental Capacity Act Code of Practice, paragraph 5.8, says that where a decision involves medical treatment, “the doctor or other member of healthcare staff responsible for carrying out the particular treatment or procedure is the decision-maker”, and that a registered attorney or court-appointed deputy is the decision-maker “for decisions within the scope of their authority”. SPS says the decision is made by the prescriber with a multidisciplinary team. A relative without a health and welfare lasting power of attorney does not consent on the person's behalf; under section 4(7) the decision-maker must take into account the views of anyone named by the person, anyone caring for them or interested in their welfare, and any attorney or deputy, where it is practicable and appropriate to consult them.

What the decision weighs. Section 4(6) requires the decision-maker to consider the person's past and present wishes and feelings, “the beliefs and values that would be likely to influence his decision if he had capacity”, and the other factors they would consider. A lifelong refusal of a medicine on religious grounds, or a known dislike of a particular treatment, belongs in that record. A valid and applicable advance decision refusing the treatment cannot be overridden by a best-interests decision: section 5(4) preserves advance decisions under sections 24 to 26.

When it should happen. For care home residents, NICE quality standard QS85, statement 6, says “Medicines should not be administered covertly until after a best interests meeting has been held.” If the situation is urgent, a less formal discussion between care home staff, prescriber and family or advocate is acceptable, but “a formal meeting should be arranged as soon as possible”. QS85 also says a health and welfare attorney should be present at the meeting.

What protects staff. Section 5 protects a person giving care or treatment only if they took reasonable steps to establish whether the person lacks capacity and reasonably believe both that they lack it and that the act is in their best interests, and section 5(3) says it does not exclude liability for negligence. The protection rests on the record. The Code, paragraph 5.52, says it is good practice to record “why they think a specific decision is in the person's best interests”, particularly where staff go against the views of somebody consulted.

One narrow exception: where Part 4 or 4A of the Mental Health Act 1983 applies to a person – most detained patients and patients on community treatment orders – regulation 11(4) says the registered person follows that Act instead; section 63 covers only treatment for the mental disorder, so other medicines still follow the Mental Capacity Act. In care homes and home care the Mental Capacity Act is the normal route.

The care plan, the MAR and home care

A decision in favour of giving medicines covertly becomes a plan for each medicine. CQC: “You must identify the need for covert administration for each medicine prescribed. Each time new medicines are added or the dose changes of an existing medicine, you must: identify the need again; make and record further ‘best interest’ decisions”. One decision covering everything a person takes, or lasting indefinitely, does not meet that.

How the medicine is given. CQC warns that “Crushing a tablet or opening a capsule before administration may make its use ‘off-licence’. You must tell the prescriber if medicines are being administered in this way.” Crushing a tablet designed to release slowly over 24 hours might cause an overdose, and some medicines become ineffective when mixed with certain foods or drinks, so CQC says to take pharmaceutical advice. SPS says altering a medicine is usually an unlicensed (off-label) activity and that “A relevant prescriber must authorise this, preferably in writing”, and that only an independent prescriber can authorise off-label use: other staff and professionals, such as a care worker or a pharmacist who is not a prescriber, can advise but cannot authorise it.

The care plan. CQC lists what a medicine care plan should include:

• the actions taken to give medicines in the normal manner;
• how medicines will be administered covertly;
• specialist input showing the method is suitable, for example crushed or mixed with certain food or drinks;
• whether the medicine is unpalatable, its adverse effects (actual or perceived), and any swallowing difficulties;
• the person's understanding of what the medicine is for and of the consequences of refusing it;
• ethical, religious or personal beliefs about treatment;
• what to do if the person refuses food or drinks.

The medicines administration record. CQC: “Medicines administration records should clearly record which medicines you administer covertly and when. This is particularly important for people with fluctuating capacity.” SPS adds that staff should document each time a medicine is given covertly, “as well as any unsuccessful attempts”. The MAR chart guide covers codes, refusals and retention. Refusals that come before a covert decision belong in the care record and on the MAR too; NICE SC1 recommendation 1.2.3 says to record the circumstances when a resident refuses a medicine and, if the resident agrees, to tell the prescriber about ongoing refusal.

Records that can be found. In AG v BMBC & SNH (2016), a persuasive first-instance decision discussed in section 05, the Court of Protection endorsed a local authority's guidance that the decision and management plan be placed in the person's medical or care home records and that “all of the above documentation must be easily accessible on any viewing of the person's records within the care/nursing home”.

Home care and supported living. NICE NG67 recommendation 1.8.2 sets the line for care workers in people's own homes: “Care workers must not give, or make the decision to give, medicines by covert administration, unless there is clear authorisation and instructions to do this in the provider's care plan, in line with the Mental Capacity Act 2005.” A request from a relative to slip a tablet into a cup of tea, however well meant, is not that authorisation. Recommendation 1.8.1 says covert administration should only take place in accordance with the Mental Capacity Act 2005 and its Code of Practice, to protect both the person and the care workers.

Reviews, deprivation of liberty and what CQC looks at

Reviews. No national interval is set for reviewing covert administration. CQC says to use it “for as short a time as possible”, to make sure “regular formal reviews are scheduled to confirm whether covert administration is still needed”, and to “base the timescale of reviews on the person's individual circumstances”. NICE SC1 1.15.3 includes “regularly reviewing whether covert administration is still needed”, and NG67 1.8.3 says the process should define “when the decision to give medicines covertly will be reviewed”. SPS lists three triggers: a dose change or a new medicine, the person regaining capacity to make decisions about their medicines, and regularly, even if nothing has changed. Set the date in the care plan and treat the triggers as reviews in their own right.

The 2016 Court of Protection judgment. In AG v BMBC & SNH [2016] EWCOP 37, a first-instance decision that is persuasive rather than binding, the judge described covert medication as “a serious interference with a person's autonomy and right to self-determination under Article 8” and said “Any change of medication or treatment regime should also trigger a review where such medication is covertly administered.” Its use “should be noted in any best interests assessment” for a DoLS authorisation, and “any change to the care plan should be notified promptly by the managing authority to the supervisory body”. The case was decided under the deprivation-of-liberty test the Supreme Court replaced in 2026, so rely on it for these recording and review points, not for its view of when a deprivation of liberty exists.

Deprivation of liberty since June 2026. CQC's covert medicines page already said: “Consider how covert medicines, such as sedatives, may be a factor in depriving a person of their liberty.” On 2 June 2026 the Supreme Court changed how a deprivation of liberty is identified. The Department of Health and Social Care's guidance, Changes to the definition of deprivation of liberty, says the assessment is now multifactorial, that “Any objection would point towards a deprivation of liberty”, and that objection could include “covert medication if objecting to medication” and “sedating medication to manage behaviour if it impacts on an individual's ability to object”. It also says “Compliance does not automatically mean someone is consenting.” Where care providers are in doubt about whether a person is objecting to their confinement, or the person moves between seeming content and seeming to object, DHSC says a referral should be made to the local authority for consideration of a DoLS authorisation, or to the Court of Protection, and that providers should continue to use DoLS processes and court applications “where there is any doubt as to whether arrangements constitute a deprivation of liberty”.

Covert medication does not automatically mean a person is deprived of their liberty, but a resident who objects to their medicines and is given them covertly is now a clear signal to look again. Deprivation of Liberty Safeguards (DoLS) authorisations cover people aged 18 and over in care homes and hospitals only; for someone receiving home care or in supported living, a deprivation of liberty is authorised by the Court of Protection, not the supervisory body. DHSC has said further interim guidance will follow, and the Liberty Protection Safeguards are not in force. The DoLS record keeping guide covers the process.

What CQC looks at. CQC's statement on the Supreme Court's judgment on deprivation of liberty, published 8 June 2026 and updated 16 June, says the judgment “has immediate effect”, that CQC will take a proportionate approach in its assessments, and that “there is no change to requirements of the Mental Capacity Act 2005 and Regulation 11”. The regulations covert administration engages are 11, 12 and 17: consent and capacity, safe management of medicines, and the record of decisions. CQC's new assessment approach, with key lines of enquiry in place of quality statements, is being piloted between June and October 2026, and “Pilot judgements have no legal standing”; it is not yet in force.

When the instruction arrives as a message

“Just crush it and put it in her yoghurt.” A covert medication policy is built around a formal decision, but many of the inputs to that decision arrive informally. The GP agrees by text to a crushed tablet. The pharmacist replies to the manager's email about a slow-release capsule. A daughter sends her view on the new antibiotic on a Sunday evening. A night carer messages: she spat it out again. And a dose change can reach the home as a message too.

Each of those is part of the record the policy depends on. The prescriber's agreement is the authorisation SPS says should preferably be in writing; the daughter's view is a consultation under section 4(7); and a dose change is exactly the event CQC says requires a fresh best-interests decision. When they sit on a manager's own phone, the change can be acted on as a new instruction without the re-decision, and the evidence of who agreed what may not be producible when an inspector, a best interests assessor or the person's representative asks for it.

ComplyChat is designed to keep those conversations on the organisation's record. Staff, and where the provider chooses, families and visiting professionals, talk in a channel the organisation holds; everyone added is told it is on the record and can object or leave; and a mobile number verified by SMS is an identity, so a relative or a bank carer does not need an account on the provider's systems. On paid plans, once its tenant is connected, conversations are kept under the retention schedules the provider runs within its own Microsoft 365 subscription. ComplyChat does not do medicines, MAR charts or care planning, and a message is not the care plan: under NG67 1.8.2 care workers act only on clear authorisation and instructions in the provider's care plan.

A question for the next governance or medicines meeting: when a prescriber changes a covertly given medicine by message, what in your policy makes that a new best-interests decision rather than a new instruction?

Questions people ask

What is a covert medication policy?

It is the part of a care provider's medicines policy that sets out how the service decides, authorises, gives, records and reviews medicines given in a disguised form without the person's knowledge. CQC says “The medicine policy should include a clear explanation of your covert medicines process”; NICE SC1 1.1.2 says a care home medicines policy should include written processes for covert administration, and NG67 1.1.2 says a home care provider's policy is likely to include one, depending on its medicines responsibilities.

Is covert medication legal?

It can be lawful in England and Wales, but only for a person who lacks capacity to decide about that medicine, where giving it covertly is in their best interests and less restrictive options have been considered, under sections 1 and 4 of the Mental Capacity Act 2005. No Act names covert medication: a carer is protected by section 5 only if they took reasonable steps to establish whether the person lacks capacity and reasonably believe that they lack it and that the act is in their best interests, that protection does not cover negligence, and it cannot override a valid and applicable advance decision refusing the treatment. A person with capacity has the right to refuse, and SPS says overriding a capable refusal is a civil wrong.

Who decides whether medicines can be given covertly?

Not one person. CQC says it “must be a multi-disciplinary team decision” that “must not be taken alone”, involving care staff, the prescriber and a family member or advocate, and NICE SC1 1.15.3 adds the pharmacist. The Mental Capacity Act Code says that for medical treatment the decision-maker is the health professional responsible for carrying it out, and a health and welfare attorney or deputy decides within the scope of their authority; SPS says crushing or otherwise altering a medicine must be authorised by a prescriber, preferably in writing.

Is mixing medicine into food always covert administration?

No. It is covert only when the person does not know they are taking a medicine; CQC's definition turns on the person's knowledge, and Scotland's Mental Welfare Commission says medication given in food or drink to make it easier to swallow, where the person knows, is not covert medication. Crushing a tablet or opening a capsule can make its use off-licence, so CQC says the prescriber must be told, and SPS says adding a medicine to food or drink is usually off-label too, needing a prescriber's authorisation.

How often should covert medication be reviewed?

No national interval is set. CQC says to schedule regular formal reviews on a timescale based on the person's individual circumstances, and to identify the need again, with a fresh best-interests decision, whenever a medicine is added or a dose changes. NICE NG67 1.8.3 says the process should define when the decision will be reviewed, and SPS adds a review if the person regains capacity and regularly even if nothing has changed.

Does covert medication need a DoLS authorisation?

Not automatically, but it is relevant. Since the Supreme Court judgment of 2 June 2026 the test is multifactorial, and DHSC lists “covert medication if objecting to medication” among forms of objection that point towards a deprivation of liberty; where it is unclear whether the person is objecting, or whether the arrangements amount to a deprivation of liberty, DHSC says to refer to the local authority for consideration of a DoLS authorisation, or to the Court of Protection. DoLS covers people aged 18 and over in care homes and hospitals only; in home care or supported living a deprivation of liberty is authorised by the Court of Protection.

Official guidance and your next step

The national sources are CQC's Covert administration of medicines (page last updated 3 November 2022); NICE SC1 recommendations 1.1.2, 1.2.3 and 1.15, NG67 recommendations 1.1.2 and 1.8, and QS85 statement 6; sections 1 to 5 of the Mental Capacity Act 2005 and chapter 5 of its Code of Practice; regulations 11, 12 and 17 of the 2014 Regulations; DHSC's Changes to the definition of deprivation of liberty and CQC's statement on the judgment; the Court of Protection's judgment in AG v BMBC & SNH [2016] EWCOP 37; and, for practice, the NHS Specialist Pharmacy Service's Covert administration of medicines: legal issues. In Scotland, the Mental Welfare Commission's good practice guide applies instead. Quotations are from those pages as published on 21 October 2026.

This guide summarises guidance that applies in England and is not legal or clinical advice. The decision for any individual is made by the prescriber and the multidisciplinary team, with pharmaceutical advice, under the Mental Capacity Act 2005.

Then do one thing: list every person your service gives a medicine to covertly, and check that each medicine has its own best-interests record, a prescriber's authorisation for the method, a care plan entry and a review date – and that the last dose change was followed by a fresh decision.