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Pharmacy inspections

Inspection reports and learning from inspections

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Monitored dosage system and care home services.

Pharmacy type


Pharmacy context

This is a very busy pharmacy in a shopping centre in the centre of town and is part of a large pharmacy multiple. It serves a diverse range of people and around 1000 care home patients within 70 care homes. It has a large retail area and dispenses approximately 18,000 NHS items per month.

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

Why this is notable practice

Monitored Dosage Systems (MDS) are assembled and checked in a well organised dedicated centre in line with the standard operating procedure (SOP). The team are separate to the main dispensary team and can work without the distractions of the retail environment. Good records of communications are made between the care home/GPs and the pharmacy, and within the pharmacy team. Dedicated patient safety reviews tailored to the care home centre are completed.

How the pharmacy did this

There was a large dedicated care home centre on one of the upper floors of the building. The centre consisted of a MDS stockroom and a care home dispensary. One half of the care home dispensary was for the assembly of the prescriptions and the other for priming and labelling of prescriptions. This ensured the prescriptions could be assembled without distractions. The MDS stockroom was used to order, store and collect the stock prior to assembly. A pharmacist was usually based in the care home centre with two or three ACTs, one of which was the designated manager for the care home service. The procedure was well organised and a communications record book was used to provide an audit trail for changes to medications and to record conversations. A care home service pharmacist information form (PIF) was used to record changes, allergies and other information to aid the pharmacist when carrying out the clinical check. A dispensing audit trail was completed and medicine identification was completed to enable identification of the individual medicines. Different systems were used to ensure the most appropriate system for the individual care homes/patients consisting of both single and multidoses. Patient Information leaflets were included and disposable equipment was used. There were separate patient safety reviews in the care home centre/MDS room with different priorities, tailored to the care home processes.

What difference this made to patients

Patients receive their medication on time with less risk of error, appropriately labelled with all the required information. Any changes to their medication and their allergy status is clearly recorded.

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