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Pharmacy inspections

Inspection reports and learning from inspections

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Clinical governance audits

Pharmacy type


Pharmacy context

A pharmacy dispenses approximately 4000 - 5000 NHS items per month. It offers services including medicines use review (MURs), new medicines service (NMS), substance misuse service, including methadone supervision and a prescription delivery service. The pharmacy supplies medication in Monitored Dosage System (MDS) trays and it offers the Emergency Hormonal Contraceptive (EHC) service via Patient Group Direction (PGD), condom distribution and Sexually Transmitted Infection testing kits.

Relevant standards

  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
  • 2.2 - Staff have the appropriate skills, qualifications and competence for their role and the tasks they carry out, or are working under the supervision of another person while they are in training

Why this is notable practice

The pharmacy reviews and continually monitors the safety and effectiveness of its services through regular audit and it tracks team member’s completion of training to ensure their knowledge is up to date

How the pharmacy did this

Managerial clinical governance audits were conducted each week. Audits were up to date and assessed a number of areas, including compliance with Controlled Drug (CD) balance checks and near miss recording, as well as ensuring dispensing incidents were being followed up in a timely manner. The pharmacy maintained CD register running balances and completed balance checks each week. Pharmacy team members each had their own individual near miss logs to encourage ownership and staff were comfortable recording the details of near misses as a learning process. The manager reviewed the near miss records at the end of each month as part of a patient safety review, the results of which were discussed as a team to identify trends action required to help reduce the risk of error reoccurrence. The team was aware of how to record dispensing incidents and all dispensing incidents were reviewed by management. Incidents were also discussed amongst the team to identify relevant learning points. Staff were appropriately trained for the roles in which they were working. Access was provided to ongoing training modules via an e-learning. Modules covered topics including safeguarding, age restricted sales and information governance. The manager tracked the training of the team to ensure team members were up to date.

What difference this made to patients

Team members record and discuss their mistakes so they can learn from what has happened and reduce the likelihood of a similar mistake in the future. The team has the skills and up to date knowledge to give good advice and information to people using the pharmacy’s services.

Highlighted standards

We have identified the standards most likely and least likely to be met in inspections, and highlighted examples of notable practice for each of these standards; to help everyone learn from others and to support continuous improvement:

  1. 1.1 Risk management
  2. 1.2 Reviewing and monitoring the safety of services
  3. 4.2 Safe and effective service delivery
  4. 4.3 Sourcing and safe, secure management of medicines and devices
  5. 2.2 Staff skills and qualifications