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Pharmacy inspections

Inspection reports and learning from inspections

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Reviewing how over-the-counter medicines which may be liable to abuse or misuse are sold

Pharmacy type


Pharmacy context

The pharmacy is located alongside other locally owned businesses in abuilt-up residential area close to the centre of the city. 

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 1.2 - The safety and quality of pharmacy services are regularly reviewed and monitored
  • 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
  • 4.2 - Pharmacy services are managed and delivered safely and effectively
  • 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

The pharmacy is supporting its team members' learning and development associated with requests for higher-risk over-the-counter medicines. This is directly in response to media coverage of GPhC enforcement action against pharmacies around the unsafe supply of codeine linctus.

How the pharmacy did this

The pharmacy team members attended a formal meeting organised by the regular pharmacist. The team discussed media articles around the unsafe supply of codeine linctus by pharmacies, and a police alert issued to the pharmacy asking the team to be vigilant when selling Phenergan as people were purchasing it to support the manufacture of illicit drugs.

The pharmacy team reviewed its processes and implemented a system to ensure that the team consistently managed requests of these higher-risk medicines in a robust manner. The pharmacy team documented the details of the meeting so that it could inform team members who were not present. This meant that each team member was reminded of the risk of abuse and misuse with these medicines and the process to follow when managing these types of requests. The pharmacy also implemented a system to identify people making repeat requests for these higher-risk medicines. This meant that a pharmacist personally managed repeated requests. And they took this opportunity to gather further information and to provide advice and signposting if necessary in a confidential manner.

What difference this made to patients

Pharmacy team members are better informed and demonstrate vigilance around managing requests of higher-risk over-the-counter medicines. This means the team are doing its upmost to keep people suffering from addiction safe, and to help them seek further support.

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