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Pharmacy inspections

Inspection reports and learning from inspections

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Inadequately maintained equipment and facilities

Pharmacy type


Pharmacy context

The pharmacy is located on a main road close to other retail shops and the town centre. It dispenses approximately 3,000 NHS prescription items and 1 private item per month. The services provided include prescription collection and delivery, substance misuse for 10 supervised and 5 unsupervised patients, medicines use reviews (MUR) (approximately 5 per month), new medicine service (NMS)(minimal), medicine dosage system (MDS) for approximately 30-35 community patients, needle exchange, blood pressure monitoring and minor ailments.

Relevant standards

  • 5.2 - Equipment and facilities are: obtained from a reputable source; safe and fit for purpose; stored securely; safeguarded from unauthorized access; and appropriately maintained

Why this is poor practice

Accuracy in the dispensing process is compromised by the use of an uncalibrated electronic counter and unstamped plastic measures. Contamination may occur due to the re-use of medicine containers, use of a cracked glass measure and the use of plastic measures which are harder to clean. More robust monitoring of the fridge temperature is required.

What the shortcomings are

There were liquid measures. Some were glass and had British Standard and crown marks but one was cracked so there was a risk of contamination from glass fragments. Two measures were plastic measures without accuracy marks. A small glass measure used for methadone solution was not clearly marked. The pharmacy also had equipment for counting loose tablets and capsules, with a separately marked tablet triangle that was used for cytotoxic drugs. An electronic counter was in use but had not been calibrated or checked for accuracy. There was a clean medical fridge. The min and max temperatures were being recorded daily and had been within range throughout the month. However, a maximum temperature of 6 degrees Centigrade and minimum temperature of 4 degrees Centigrade had been recorded on the morning of the inspection but the maximum temperature was actually reading 21.9 degrees Centigrade and minimum temperature was 5.6 degrees Centigrade at the start of the inspection. The member of staff who had recorded the fridge temperature that morning was not clear on how the thermometer worked. The thermometer was reset and was reading maximum temperature of 9.9 degrees Centigrade and a minimum temperature of 5.5 degrees Centigrade at the end of the inspection. This was outside of the acceptable range of 2-8 degrees Centigrade.

What improvements are required

All equipment in use must be maintained in a good state of repair and replaced as necessary. Suitable equipment should be provided for measuring fluids and counting tablets, etc, with risks of cross contamination identified and mitigating action taken.

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