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Pharmacy inspections

Inspection reports and learning from inspections

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Supplying naloxone to people to help prevent death from opioid overdose.

Pharmacy type


Pharmacy context

The pharmacy is located in a town centre. It sells over-the-counter medicines and dispenses NHS and private prescriptions. It also supplies medicines in multi-compartment compliance aids to people living in their own homes. And it delivers medicines to people’s homes.

Relevant standards

  • 1.8 - Children and vulnerable adults are safeguarded
  • 4.2 - Pharmacy services are managed and delivered safely and effectively

Why this is notable practice

The pharmacy is widening the availability of a life-saving emergency treatment used for opioid overdose. The pharmacy team engages with drug misusers and those close to them to explain the benefits of having a supply of naloxone at home. And it uses nationally recognised resources to support the conversations.

How the pharmacy did this

The pharmacy was part of a locally commissioned naloxone supply trial. People who came to the pharmacy to collect their medicines for treatment for opioid dependency were given prefilled syringes of naloxone. Naloxone was a life-saving medicine which could be used in an emergency to treat opioid overdose. The pharmacy team had also given pre-filled syringes to people who supported or cared for anyone who was vulnerable to overdose. This included friends and family members close to them who may need to administer it to them. The pharmacy had a separate entrance which was used by those accessing substance misuse services. This allowed people to enter and leave discretely.

Pharmacy team members had all attended an online training event and had learned about the benefits of naloxone, how it worked and how to administer it in an emergency. The pharmacy had sourced a list of prompts from Public Health England and had a laminated sheet which they kept close to hand. The list of prompts had helped team members to start a conversation with people about the benefits of carrying naloxone. The pharmacy also had placebo demonstration devices to support these conversations and ensure that people understood what they needed to do to administer the naloxone effectively.

What difference this made to patients

People who will benefit from having a supply of naloxone can obtain it from the pharmacy. And they will receive information on how to administer it correctly. This will lead to fewer deaths from opioid overdose.

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