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Pharmacy inspections

Inspection reports and learning from inspections

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Insufficient staffing level

Pharmacy type


Pharmacy context

The pharmacy is located next door to a GP practice. It dispenses approximately 12,500 NHS prescription items per month and provides medicine use review (MUR), monitored dosage system (MDS) for 200 community patients, NHS enhanced service for emergency supply of medicines, discharge medicine review (DMR), diabetic sharps disposal, influenza vaccinations for private and NHS patients under patient group directives (PGDs), emergency hormonal contraception (EHC) under a PGD, smoking cessation, prescription collection and delivery, palliative care, blood pressure monitoring and weight management as services.

Relevant standards

  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
  • 2.1 - There are enough staff, suitably qualified and skilled, for the safe and effective provision of the pharmacy services provided
  • 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

The level of trained staff is inadequate for the safe operation of pharmacy services. This is leading to a chaotic working environment, routine training and date checking not taking place and long delays for patients awaiting their medication.

What the shortcomings are

There was a lack of trained staff for the volume of work. The team included a pharmacist manager, a second pharmacist, a pharmacy technician , a dispenser, a trainee dispenser, a healthcare assistant and a delivery driver. Staff were under significant pressure with many patients waiting for extended periods to receive their medication, including patients waiting for their MDS . Targets for MURs added to the pressures on staff. A large number of prescriptions were waiting for an accuracy check and to be dispensed. The pharmacy technician was dispensing the 200 MDS packs that were due out to patients on the day. Pharmacy services appeared to be provided in a chaotic, untidy and disorganised manner. There was a large amount of excess stock stored untidily on the dispensary floor and stock room floor. The medicines stock on the shelves was stored untidily with different medicine containers on top of each other and mixed together. There was very limited workspace due to many prescriptions being dispensed, checked and MDS being assembled. At times there was no clear bench space for dispensing prescriptions. Patients prescribed warfarin, methotrexate or lithium were not highlighted to ensure they received appropriate counselling upon collection of their prescription. Open stock bottles of oramorph liquid with limited shelf life did not have the date of opening written on them. Date checking of dispensary stock and retail stock had not been carried out for some time. Out of date medicines had not been highlighted as short dated. None of the staff had completed any ongoing training for a considerable period of time and a dispenser had not completed any training since commenced in her role due to workload pressure and a lack of staff.

What improvements are required

The staffing level and skills mix for the services offered should be reviewed together with completion of mandatory training and compliance with SOPs, especially in relation to monitoring of high risk patients and date checking of stock.

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