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Pharmacy inspections

Inspection reports and learning from inspections

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Reviewing suitability of the pharmacy environment for vaccination services

Pharmacy type


Pharmacy context


Relevant standards

  • 3.1 - Premises are safe, clean, properly maintained and suitable for the pharmacy services provided

Why this is notable practice

The pharmacy is reintroducing services which it had been unable to provide during the height of the COVID-19 pandemic. Services include the completion of travel vaccination schedules and Hepatitis B vaccinations to healthcare professionals returning to work. It is risk assessing the way in which services are managed so they can be delivered safely. And it is doing this by taking procedural and environmental factors into account. This includes the pharmacy’s layout, the suitability of its consultation rooms and the air quality within them. It is also ensuring that its services are provided in accordance with up-to-date and relevant published guidance.

How the pharmacy did this

The pharmacy had an enclosed suite of consultation rooms with a waiting area outside. Each service had its own clinic days and only one service was provided each day. The pharmacy had delivered the services by appointment. And appointments were staggered so that no-one was waiting while someone else was being seen. The pharmacy had also ensured that it had sufficient time to clean rooms and equipment thoroughly between appointments. And people had been sent text messages requesting that they arrived on time, to minimise the time they were in the pharmacy. This was so that the pharmacy could maintain social distancing and reduce the risk of people coming into contact with one another.

The consultation rooms did not have any windows to provide fresh air. The superintendent pharmacist had completed some research about how to manage this issue. He had looked at PHE guidance and had equipped consultation rooms with a mechanical heat recovery system to control the concentration of airborne particles (contaminants) in each room. The system installed had provided ten to twelve complete air changes per hour. He had also ensured that each room was thoroughly cleaned in accordance with PHE infection prevention and control guidance. The pharmacy had followed vaccination guidance as set out by its current patient group direction, guidance from the local pharmaceutical committee and general vaccination guidance produced by NHS England for vaccinations provided during the pandemic. Team members were using the recommended personal protective equipment and ensuring that it was safely disposed of promptly after each consultation.

As a result of all these measures, the pharmacist felt that the pharmacy was able to deliver a flu vaccination service. But it was also ready to review its procedures in accordance with any future published guidance.

What difference this made to patients

Patients and healthcare professionals have access to a range of pharmacy services which supports their general wellbeing, protects their health and aids their return to work.

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