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Pharmacy inspections

Inspection reports and learning from inspections

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Recording and sharing examples when person-centred care makes a difference to people’s health and wellbeing.

Pharmacy type


Pharmacy context

This is a community pharmacy which is part of ‘small multiple’, locatedin a large village. It dispenses private and NHS prescriptions includingsupplying medicines in multi-compartment compliance packs. The pharmacy offersa repeat prescription collection service and a delivery service. It alsoprovides NHS smoking cessation and substance misuse services. The pharmacy teamadvises on minor ailments and medicines use. And supplies a range ofover-the-counter medicines, including supply on the NHS Pharmacy First service.

Relevant standards

  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
  • 1.8 - Children and vulnerable adults are safeguarded
  • 2.2 - Staff have the appropriate skills, qualifications and competence for their role and the tasks they carry out, or are working under the supervision of another person while they are in training
  • 2.4 - There is a culture of openness, honesty and learning
  • 2.5 - Staff are empowered to provide feedback and raise concerns about meeting these standards and other aspects of pharmacy services

Why this is notable practice

When the actions of pharmacy team members lead to positive health and wellbeing outcomes for people using their services, the team feels empowered to record and share this with the superintendent pharmacist (SI). The SI shares these examples with the other pharmacies within the company to promote shared learning. Recording these events and actions encourages team members to reflect on how the pharmacy meets GPhC standards. This reflective approach helps to support learning, development and confidence and provide good person-centred care.

How the pharmacy did this

The pharmacy team members were all encouraged to record events or incidents that led (or may lead) to positive outcomes for people using their services. The SI had developed a ‘tell-me log’ to help engage and encourage all team members to play their part in showing how they met GPhC premises standards, while doing their best for people. It was developed with the ‘show me, tell me’ approach of the GPhC inspection model in mind. It helped team members understand how adopting a person-centred approach when providing services meant they would consistently provide a beneficial service to people and meet the GPhC standards.

The ‘tell-me log’ was easily accessible to all team members on the company intranet to enable any team member to briefly record the event. They recorded their name, date, event and outcome it helped meet. The SI viewed these records and shared some examples across the company for all teams to reflect on and learn from. There was a culture of ‘nothing’s too trivial’ to record, and team members positively engaged with the initiative.

This process had been in place within the company for a few years, but it had been used more frequently and for a more diverse range of entries during the COVID-19 pandemic. Team members had made an increased contribution to people’s care over the past few months due to pressures on other healthcare providers, and their concern for people’s wellbeing during the pandemic.

Examples recorded included:

Following a GP telephone consultation, the person attended the pharmacy in person. The pharmacist was concerned about the severity of the person’s condition and referred the person back to the GP. This resulted in onward referral to hospital and appreciation from both the person patient and GP.

The pharmacy effectively liaising with other agencies regarding concerns for a vulnerable person.

Team members spending time chatting and empathising with people using the pharmacy who they noticed were low in mood. The pharmacy had received phone calls and cards from people saying how much this meant to them.

Team members often discussed these events and encouraged each other to record appropriate examples. They got a positive feeling from seeing several examples written down, particularly on challenging days.

What difference this made to patients

When pharmacy teams share the positive health outcomes from their actions it means other teams in the company can learn from this and make a difference to the people that use their pharmacy services. Team members keep motivated and focussed on meeting GPhC premises standards. This means people can feel assured they are receiving a good and consistent service.

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