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Pharmacy inspections

Inspection reports and learning from inspections

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Patients’ feedback about their experience of pharmacy’s services not acted upon.

Pharmacy type


Pharmacy context

The pharmacy is situated in a small retail park. It dispenses around 15,000 items a month, with over 150 patients receiving mediciation in monitored dosage system packs. Services provided include medicines use reviews (MURs) and new medicines services (NMS); substance misuse services; smoking cessation; emergency hormonal contraception (EHC); blood pressure measurement and diabetes testing. A locum pharmacist was present for the inspection. The pharmacy is recruiting for staff to complete the team.

Relevant standards

  • 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
  • 1.7 - Information is managed to protect the privacy, dignity and confidentiality of patients and the public who receive pharmacy services
  • 1.8 - Children and vulnerable adults are safeguarded

Why this is poor practice

The pharmacy does not respond appropriately to feedback from people.

What the shortcomings are

The public area had been re-fitted and was bright and modern, and presented a professional image. However, there were only two seats which meant that people had to stand while waiting for their medicine. This meant the front-shop area was crowded and it was difficult for pharmacy team members to identify who was waiting for dispensed medicines and who was queuing for the medicines counter. This made ‘serving’ people slow and ineffective. The crowded nature of the front shop created pressure for team members dispensing prescriptions, potentially increasing the likelihood of errors being made. People can overhear conversations between pharmacy team members and other people when medicines are supplied. People were complaining to team members about the lack of seating. Several comments about this had been made since the re-fit several weeks previously. No action had been taken to address the issues. Some elderly people, and some with limited mobility were unable to sit while waiting for their dispensed medicines.

What improvements are required

Review work flow, particularly in terms of where/how dispensed medicines are handed out to maintain dignity and confidentiality. Provide more seating, and a better-defined waiting area, with signage to offer seats to those who would benefit most. Give realistic waiting times for walk-in prescriptions to minimise the number of people waiting on the premises.

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