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Pharmacy inspections

Inspection reports and learning from inspections

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Insufficient staffing level

Pharmacy type


Pharmacy context

This was a health centre pharmacy serving a mixed demographic including deprivation, affluence and an elderly population, dispensing around 8000 NHS items per month and a small quantity of private dispensing. The NHS items included supply to over 100 patients in MDS trays. Other NHS services provided were the standard Scottish pharmacy contract services. Services provided under PGDs were unscheduled care, emergency hormonal contraception, chloramphenicol ophthalmic products and post-immunisation paracetamol.

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
  • 1.4 - Feedback and concerns about the pharmacy, services and staff can be raised by individuals and organizations, and these are taken into account and action taken where appropriate
  • 2.1 - There are enough staff, suitably qualified and skilled, for the safe and effective provision of the pharmacy services provided
  • 2.5 - Staff are empowered to provide feedback and raise concerns about meeting these standards and other aspects of pharmacy services
  • 4.1 - The pharmacy services provided are accessible to patients and the public
  • 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
  • 5.1 - Equipment and facilities needed to provide pharmacy services are readily available

Why this is poor practice

The main risk in this pharmacy was lack of staff, resulting in many routine activities not being undertaken, high staff stress levels, increased prescription waiting times resulting in many patients in the pharmacy waiting for prescriptions, and cluttered dispensary due to stock arriving and not being put away in a timely manner.

What the shortcomings are

A shortage of staff led to a high number of collection service prescriptions waiting to be dispensed, prescriptions with owings taking up space on the dispensing benches and considerable time wasted looking for prescriptions that had not yet been dispensed as expected due to the backlog. The pharmacist was having to do quite a lot of dispensing and self-checking, including for Methadone instalments. An accuracy checking technician who worked full-time was unable to accuracy check prescriptions as she was required to dispense and label. MDS trays were currently running one week behind, resulting in increased pressure leading to risk of error. Some medicines were overstocked as items were reordered as they could not be located, as staff had not had time to put stock away in the correct place. The GP surgery had made changes to its processes, including ceasing repeat prescriptions and emergency prescriptions which added to the pharmacy's unmanageable workload.

What improvements are required

The staffing level needs to be reviewed to ensure that there are sufficient numbers to meet the defined governance arrangements and so ensure safe service provision.

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