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Pharmacy inspections

Inspection reports and learning from inspections

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Safeguarding vulnerable patients

Pharmacy type


Pharmacy context

​The pharmacy was a ‘Healthy Living Pharmacy’ co-located with a doctor’s surgery dispensing over 20,000 NHS prescription items each month.  10% of these were acute ‘walk-in’ patients and half were assembled into monitored dosage systems (MDS) for domiciliary patients.  Advanced and enhanced NHS services offered by the pharmacy were medicine use reviews (MURs), new medicine service (NMS), sexual health, supervised consumption of methadone and buprenorphine, smoking cessation (nicotine replacement), weight management scheme, alcohol awareness scheme and seasonal ‘flu vaccinations. 

Relevant standards

  • 1.1 - The risks associated with providing pharmacy services are identified and managed
  • 1.8 - Children and vulnerable adults are safeguarded

Why this is notable practice

Vulnerable patients are proactively identified and concerns about them are appropriately escalated and acted on.

How the pharmacy did this

The staff had a good understanding of safeguarding issues. They had all received level 2 training from NHS England on the safeguarding of both children and adults and they had completed ‘Dementia Friends’ training. The pharmacist had done face-to-face training with the Clinical Commissioning Group (CCG). Local telephone numbers were available to escalate concerns relating to both children and vulnerable adults. The pharmacy had a system for recording any safeguarding concerns. It had set up a ‘Box Watch’ scheme jointly with the surgery under which any dosette patient that they had non-adherence concerns about, was asked to bring their old box back to the pharmacy each week. Any concerns were then escalated to the doctor.

Patients at risk of suffering from a stroke, developing Type II diabetes or having undiagnosed chronic obstructive pulmonary disorder (COPD) were proactively identified. Patients were counselled and asked to fill in a comprehensive questionnaire. Cohorts of patients at risk were identified. The pharmacy had identified a cohort of 148 patients of which 10 were identified as being at high risk of suffering a stroke. They were immediately referred to the surgery for further tests. A cohort of 89 patients had been identified as being at risk of developing Type II diabetes. 25 of these were identified as being at high risk and referred for further tests. 3 of these patients were subsequently found to have undiagnosed Type II diabetes. In addition, of the 89 patients initially identified, 59 were put on the weight management scheme. Patients with a body mass index (BMI) of greater than 30 were referred to Weight Watchers and their first month’s subscription was free.

A cohort of 44 patients was identified as having potentially undiagnosed COPD. 7 of these patients had a FEV1 (forced expiratory volume at the end of the first second of forced expiration) of less than 70% of the predicted level. These patients were referred to the surgery for spirometry tests. 2 of the 7 patients were found to be suffering with undiagnosed COPD. The pharmacy had a 70% quit rate after 4 weeks on their smoking cessation course.

What difference this made to patients

Patients at risk of suffering from a stroke, developing Type II diabetes or having undiagnosed chronic obstructive pulmonary disorder (COPD) were proactively identified to ensure they receive the treatment they need.

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