| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy team did not have standard operating procedures in place to cover all the services that were taking place at the pharmacy. |
All the SOPs have been reviewed and checked against each and every service provided. They have been printed and the staff are in the process of reading and signing them all. This will be completed by the end of next week at the very latest. All SOPs are dated and version controlled. |
05/09/2025 | 03/09/2025 |
| 1.1 | The pharmacy team did not keep an up to date near miss log record. |
Implement a new Near Miss Recording System, with daily logging by staff and weekly review if any major or a new trend of near miss is identified or monthly review meetings to identify trends and take corrective action. Train all staff on use of the log and the importance of timely and accurate reporting. |
05/09/2025 | 03/09/2025 |
| 4.2 | The pharmacy team operated a weight loss service, but did not have any specific procedures or risk assessments in place for this. |
Update a specific SOP for the weight loss service including patient eligibility criteria, clinical checks, record-keeping, and follow-up. Complete a full risk assessment and train staff involved in the service. Enrol the Pharmacist on the ECG PGD for the weight management and being trained on the risk assessment procedure. Also checked with the indemnity insurance provider to check that the service has been included. |
05/09/2025 | 03/09/2025 |
Pharmacy inspections
Inspection reports and learning from inspections