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Pharmacy inspections

Inspection reports and learning from inspections

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Poor management of Controlled Drugs

Pharmacy type


Pharmacy context

The pharmacy provides dispensing services at a distance, which means people cannot access the pharmacy premises. People can access the pharmacy website and contact the pharmacy by telephone. The pharmacy dispenses NHS prescriptions. The pharmacy requests prescriptions on behalf of people. And it delivers medication to people’s homes.

Relevant standards

  • 1.6 - All necessary records for the safe provision of pharmacy services are kept and maintained
  • 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 poor practice

Poor management of CDs with a lack of maintenance of CD registers and inadequate arrangements for destruction of returned CDs

What the shortcomings are

The pharmacy had not completed any CD register entries for a considerable period of time which breached legal requirements.. The Superintendent Pharmacist had copies of the prescriptions and the invoices but had not made any entries in the CD registers. The pharmacy had a box of controlled drugs (CDs) returned by people which were not stored in the CD cabinet. The pharmacy had not made a record of many of these returned CDs. So, the team may not know that all the CDs returned to the pharmacy had been correctly destroyed.

What improvements are required

The pharmacy should review its procedure for management of CDs including destruction of returned CDs to ensure it is fully compliant with legal requirements and GPhC guidance.

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