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Pharmacy inspections

Inspection reports and learning from inspections

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Reintroducing vaccination services during the COVID-19 pandemic

Pharmacy type


Pharmacy context


Relevant standards

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

Why this is notable practice

Following the easing of restrictions on the provision of pharmacy services, the pharmacy is restarting a travel clinic and is administering vaccinations. It is applying protective measures to reduce the risk of transmitting COVID-19.

How the pharmacy did this

The pharmacy had closed its travel clinic during the height of the COVID-19 pandemic. But the team realised that several patients who had started their vaccination regimes before the service closed would not be fully protected. This was because they had been unable to complete the required number of vaccinations. This included people who had not been able to have the final dose of their hepatitis B regimen. So, the pharmacy decided that as soon as it was able to provide the service safely again, it would do so.

When restarting the service, the pharmacy contacted everyone who had been unable to complete their vaccination regimen. Pharmacy team members informed people they would be required to fill out a self-declaration questionnaire to establish that they, or any members of their household, were not displaying symptoms of COVID-19. And that they had not had COVID-19 in recent weeks. They were also required to give permission for the pharmacy to take their temperature, using an infrared thermometer of appropriate quality, before a vaccination was given. Staff stood at arm’s length when taking people’s temperatures. And they wore the appropriate personal protective equipment (PPE), in accordance with current Public Health England (PHE) advice.

The pharmacy had followed general vaccination guidance issued by NHS England and the National Travel Health Network & Centre (NaTHNaC) for health professionals providing vaccinations during the pandemic. And so, when administering vaccinations, the pharmacist wore full PPE including a face mask, visor, gloves and disposable apron. Single-use PPE was disposed of safely immediately after the vaccination was administered. The visor was thoroughly cleaned using an appropriate cleansing fluid. The pharmacy ensured that strict handwashing procedures were in place for both the pharmacist and people accessing the service. And the consultation room was thoroughly cleaned between appointments.

What difference this made to patients

The pharmacy is able to complete vaccination schedules whilst protecting both pharmacy team members and the person receiving the service from the risks associated with transmitting COVID-19.

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