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Pharmacy inspections

Inspection reports and learning from inspections

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Meaningful interventions through the NHS Discharge Medicines Service

Pharmacy type


Pharmacy context

The pharmacy specialises indispensing prescriptions through a centralised delivery service. It deliversmost medicines to people’s homes. Some medicines are delivered to people’slocal branch of the pharmacy chain for them to collect. The premises is not physicallyaccessible to members of the public due to the distance selling model in place.

Relevant standards

  • 4.2 - Pharmacy services are managed and delivered safely and effectively

Why this is notable practice

The pharmacy has an effective system to identify and act on referrals from hospitals for the NHS Discharge Medicines Service (DMS). The pharmacy ensures the service is a core part of its daily activity. And its team make meaningful interventions through the service which benefit people recently discharged from hospital.

How the pharmacy did this

The pharmacy had clear designated roles for its team members. This included assigning a duty pharmacist each day to support with NHS consultation services such as DMS and the New Medicine Service (NMS). The pharmacy received its referrals for DMS through a secure clinical service platform. The team’s approach to managing workload meant it picked up referrals and acted upon them in a timely manner.

The pharmacy team understood the three different stages involved in delivering the service and made meaningful interventions at each stage of the service. Team members liaised effectively with other healthcare professionals at the hospital and GP surgery to resolve queries and ensure people received the medicines they needed following discharge from hospital.

The pharmacy had identified changes and omissions to a person’s medicines when acting on these referrals. By speaking with the healthcare professionals at the hospital and on a separate occasion with the GP surgery team, the pharmacy ensured the person received the correct medication. The pharmacy intervened after speaking with the person’s carer, realising the medicine regime was not being followed correctly, after the person had been discharged from hospital. This was rectified and the pharmacy shared the learning with the other healthcare professionals involved.

What difference this made to patients

The pharmacy demonstrates how its interventions at each stage of the DMS process supports people in taking their medicines safely. It is actively working to prevent harm, reduce readmissions to hospital and to improve health outcomes for people recently discharged from hospital.

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