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Pharmacy inspections

Inspection reports and learning from inspections

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Staff are encouraged to provide feedback and raise concerns

Pharmacy type


Pharmacy context

This is a community pharmacy that mainly dispenses NHS prescriptions. People can ask to have their blood pressure measured. It offers Medicines Use Reviews (MURs) and New Medicine Service (NMS) checks. It supplies medication in multi-compartment compliance packs to assist people who need help managing their medicines. It administers flu vaccinations in the winter season. The pharmacy is in the process of obtaining a patient group direction for emergency hormonal contraception. And it currently offers the C-Card service.

Relevant standards

  • 2.5 - Staff are empowered to provide feedback and raise concerns about meeting these standards and other aspects of pharmacy services

Why this is notable practice

Team members are actively encouraged to offer suggestions and raise any concerns. And this helps improve the pharmacy’s services.

How the pharmacy did this

The pharmacy had a good culture of sharing learning and making suggestions to improve its services. Team members had regular monthly meetings. The meetings were documented, and included discussions around any dispensing incidents, new products, and company updates. Near misses were reviewed monthly to identify any patterns, and the results were discussed in the meetings. A recent error had occurred between two medicines whose names sounded similar. The dispenser said that it had been discussed in one of their regular staff meetings. The team had identified that the wrong item had been picked by a dispenser who usually worked in another store, and team members thought it could have occurred because the layout of their ‘top 150’ medicines was different to the dispenser’s usual store. The pharmacist said that in future she would ensure that she went through the layout of the dispensary with any new team members.

Team members described how they had regular discussions including any incidents that had occurred and any company updates. They felt comfortable about raising any concerns. They said that they were actively asked for any concerns they had or any suggestions on how to make the services safer. The trainee technician gave an example of a suggestion that had been made at one of their staff meetings. She said that they had identified an increased number of near misses when dispensing multi-compartment compliance packs which occurred when the dispenser had to cover the medicines counter as well. And this had meant that they had to leave the dispensing part-way through and come back to it. She explained that they had now changed the system so that they only dispensed the packs when there were two team members working, so that one could cover the counter. The impact of this had been monitored by the team members and the number of near misses had decreased as a result.

What difference this made to patients

People receive services which are continually made safer through team members regularly discussing any incidents. And team members actively make suggestions to improve the safety of the pharmacy's 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