| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | Pharmacy team members have not read the pharmacy's written procedures. And they can not access the full range of written procedures, which means they can not refer to them to ensure they are working in a consistent and safe way. The team does not have access to any updated written procedures, risk assessments or business continuity plans for its recently changed way of working where some medicines are assembled off site in a separate hub pharmacy. They rely on practical training they receive and so may not always work in the safest and most consistent way. |
Staff including the manager are reminded on where all the documentations relating to SOPs and other relevant materials relating to the pharmacy and hub&spoke operations can be accessed on the drive. |
17/10/2025 | |
| 1.2 | The pharmacy does not have a robust process for team members to follow to manage mistakes made during the dispensing process. And team members cannot show any learning or actions taken following mistakes. This means they miss opportunities to improve ways of working and making services safer. |
The staff including the manager has been reminded on where the near miss and dispensing error log is and how they can access it. They have been re-trained on how to record and learn from errors made during the dispensing process, as well as the updated version with regards to errors made during the hub&spoke process. |
17/10/2025 |
Pharmacy inspections
Inspection reports and learning from inspections