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Pharmacy inspections

Inspection reports and learning from inspections

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Insufficient staffing level

Pharmacy type


Pharmacy context

This is a high street pharmacy in a town of mixed demographic, which relocated into larger premises. It dispenses around 7700 NHS items per month and a small quantity of private dispensing. Dispensing volume is increasing each month. The NHS items include supply to over 100 people in monitored dosage system (MDS) trays. Other services include Opiate replacement therapy and repeat prescriptions.

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 2.1 - There are enough staff, suitably qualified and skilled, for the safe and effective provision of the pharmacy services provided
  • 4.2 - Pharmacy services are managed and delivered safely and effectively
  • 4.3 - Medicines and medical devices are: obtained from a reputable source; safe and fit for purpose; stored securely; safeguarded from unauthorized access; supplied to the patient safely; and disposed of safely and securely

Why this is poor practice

There are insufficient staff to provide safe and effective pharmacy services.

What the shortcomings are

There was a significant backlog of work. Several baskets full of dispensed items waiting to be checked and several baskets containing checked medicines waiting to be put onto retrieval shelves were stacked on the checking bench from the previous day. There was often insufficient time to complete dispensing and checking by the end of the day which meant that at the start of the day there was already a backlog. Dispensers were interrupted frequently during the dispensing process to serve on the medicines counter, as there were 2 tills on this counter and no medicine counter assistants. Individual staff competency sheets confirmed which SOPs each staff member had read and was working to. However, the date checking SOP was not being followed by staff who had signed it and date expired items had not been highlighted as required by the SOP.

What improvements are required

Staffing levels must be reviewed to ensure services can be delivered safely. There should be sufficient prescription checking capacity to avoid work being routinely left until the next day. All staff members must be compliant with SOPs, and not sign these until they understand them, and work within them. Date checking must be undertaken regularly and short dated/expired items highlighted and removed.

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