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Pharmacy inspections

Inspection reports and learning from inspections

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Reviewing the supply of medicines in multi-compartment compliance packs through the use of risk assessments

Pharmacy type


Pharmacy context


Relevant standards

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

Why this is notable practice

The pharmacy uses risk assessments to manage the volume of multi-compartment compliance packs it supplies. It uses the risk assessments to ensure that it can focus the service on those people whose health would benefit from having their medicines dispensed in this way. And it is able to use its resources more effectively by reducing the number of packs dispensed for people who don’t need them.

How the pharmacy did this

The pharmacy’s workload had increased significantly at the beginning of the pandemic. The pharmacy team recognised that dispensing multi-compartment compliance packs could increase risk. This was due to handling medicines during the dispensing process, even when wearing appropriate personal protective equipment. The pharmacy also considered the added risk associated with time and resources required for providing the service.

To manage these risks the team had conducted an audit of the service. It had reviewed the needs of each person who had their medicines supplied in multi-compartment compliance packs and had spoken to them individually, or their carers where appropriate. It discovered that while some people had a genuine need of the service and would struggle without it, two thirds could manage well with an alternative means of support. The team had established that some people were able to manage a 28-day supply of their medicines in their original packs with the addition of a Medicine Administration Record (MAR) chart to help them manage their dosage times. Others needed their medicines to be dispensed in individual packs containing only seven days’ worth of medication, which the pharmacy then supplied either weekly or monthly. Team members provided support and counselling to people and or carers to support them with the change. And it reviewed the outcomes for each patient regularly to ensure that people were not disadvantaged by the changes.

What difference this made to patients

The pharmacy team is able to deliver its services more effectively to ensure that people receive their medicines safely and in the most appropriate way. People have access to support and counselling to ensure that, despite changes to the way they receive their medicines, they get maximum benefit from them. And are able to take them safely and effectively. The pharmacy team manages its resources to ensure that people benefit from all of its services.

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