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There are good arrangements in place to ensure medicines and medical devices are supplied to patients safely by the delivery service.

The substance misuse service and the needle exchange service are managed safely, reducing the risk of patients receiving the wrong medication or receiving a needle-stick injury.

The supplies made as part of the registerable activities are done so in an organised manner and complete audit trails are in place to ensure that problems can be swiftly identified.

There are insufficient staff to provide safe and effective pharmacy services.

There are inadequate governance arrangements particularly in respect of controlled drugs (CDs) . A range of standard operating procedures define the processes and procedures at the pharmacy, however most of these are out of date and a review is needed to ensure they reflect current pharmacy practices and are adhered to by staff. Not all near-misses and errors are recorded and reviewed to ensure that all of the emerging risks are managed. Not all of the necessary records are being maintained and CDs are not properly managed.

The pharmacy proactively identifies and manages risks through a range of methods, including, having designated areas for separating activities; flagging specific patients needing counselling or more than one prescription; and tracking the progress of prescriptions.

There are no procedures in place to record and learn from dispensing incidents and near misses are very infrequently recorded and the pharmacy team cannot demonstrate any learning from these. The Standard operating procedures (SOPs) that were in place for some dispensary tasks were not followed, including that for Monitored dosage system (MDS) trays.

There are poor governance procedures in place and an insufficient level of staff for the services provided. Overall, there is inadequate assurance that risks are identified and managed and that procedures are reviewed and monitored. Stock is haphazardly and unsafely stored. Schedule 2 controlled drugs are delivered against faxed prescriptions with no assurance that these have not also been supplied by local pharmacy. There are insufficient employed staff to safely provide the services offered by the pharmacy. Many of the staff are newly employed, unsure of their responsibilities and unable to make professional judgements. The trainees are not supported with their learning and there is no overall culture of learning at the pharmacy. Record-keeping is poor and some staff do not understand safeguarding issues. Patient-sensitive information is not kept securely. Some areas are in need of routine maintenance and repair and the temperature in parts of the dispensary is too high for the safe storage of medicines.

The Superintendent pharmacist/owner normally worked alone and covered the majority of the hours. Although, the pharmacy was generally quiet so the pharmacist was able to manage the dispensing workload (a locum pharmacist was employed very occasionally) routine tasks such as record keeping and cleaning were not maintained to ensure services are provided in a safe and organised environment. The pharmacy does not have adequate governance arrangements in place. Records required for the safe and legal provision of pharmacy services were not maintained in accordance with requirements.

The pharmacy doesn’t manage risks adequately and the way it operates and stores its medicines increases the risk of mistakes happening. It has procedures in place but these are not always followed and are not reviewed regularly. Additionally, it doesn’t review its services when things go wrong and the pharmacy does not have sufficient capacity to provide the volume of services it does.