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Pharmacy inspections

Inspection reports and learning from inspections

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Palliative care medicines

Pharmacy type


Pharmacy context

This was a high street pharmacy dispensing around 2800 NHS items per month and a small quantity of private dispensing. There were few walk-in prescriptions, most being from the surgery or for care homes. The population served was predominantly elderly. The NHS items included supply to around 48 patients in Monitored Dosage System (MDS) trays. Pharmaceutical services were provided for 5 care homes. Other NHS services provided were – Chronic Medication Service (CMS), Minor Ailments Service, smoking cessation and the gluten free food prescribing service. The local NHS palliative care service was delivered from this pharmacy. Services provided under PGDs were unscheduled care, smoking cessation, emergency hormonal contraception, chloramphenicol ophthalmic products and post-immunisation paracetamol. A substance misuse service was provided to a small number of patients.

Relevant standards

  • 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 notable practice

Palliative care medicines are carefully managed including supporting prescribers to ensure timely supply.

How the pharmacy did this

The pharmacy provided a palliative care service. When prescriptions for palliative items were generated, a barcode was provided to the pharmacy before prescriptions were issued to ensure there were no stock problems, and prescriptions were checked for clarity and legality. This saved time and prevented items that being returned to prescribers. Medicines required to deliver the service were checked regularly to ensure they were in date and the correct quantity was available. The non-controlled drug items were stored together in an area away from other medicines. The pharmacist attended regular meetings with health colleagues to discuss issues and ensure compliance with current policy.

What difference this made to patients

End of life care patients are able to receive the medication they need when they require it to maintain their quality of life.

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