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Pharmacy inspections

Inspection reports and learning from inspections

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Insufficient staffing level and weaknesses in monitoring and review mechanisms, record keeping and cleanliness

Pharmacy type


Pharmacy context

This is a 100 hour community pharmacy located on a busy road. The pharmacy dispenses approximately 1200 NHS items in a typical month. Apart from dispensing Methadone and Buprenorphine for 10 patients and an occasional delivery service no other enhanced or advanced services are currently offered.

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 1.6 - All necessary records for the safe provision of pharmacy services are kept and maintained
  • 2.1 - There are enough staff, suitably qualified and skilled, for the safe and effective provision of the pharmacy services provided
  • 3.3 - Premises are maintained to a level of hygiene appropriate to the pharmacy services provided
  • 4.2 - Pharmacy services are managed and delivered safely and effectively

Why this is poor practice

The Superintendent pharmacist/owner normally worked alone and covered the majority of the hours. Although, the pharmacy was generally quiet so the pharmacist was able to manage the dispensing workload (a locum pharmacist was employed very occasionally) routine tasks such as record keeping and cleaning were not maintained to ensure services are provided in a safe and organised environment. The pharmacy does not have adequate governance arrangements in place. Records required for the safe and legal provision of pharmacy services were not maintained in accordance with requirements.

What the shortcomings are

The dispensary was cluttered and untidy and the whole premises needed a deep clean. There was a dispensary sink for medicines preparation and separate sink in the toilet for handwashing, both had hot and cold running water, but both sinks needed a good clean. Shortcomings in respect of record keeping due to a lack of staff included: on many occasions the responsible pharmacist had failed to record the end of their tenure; incomplete records of controlled drugs; prescriptions for supply of methadone and invoices of methadone obtained from the wholesalers not entered; missing registers for OxyContin 10mg and 20mg; records of patient returned controlled drugs unavailable; records of private prescriptions not up to date; private prescriptions not entered in the Prescription only medicines book; signatures not routinely obtained from recipients of delivered medicines.

What improvements are required

The staffing level should be reviewed to ensure that it is sufficient to enable proper record keeping, maintenance of a high standard of cleanliness and a safe and organised environment.

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