| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has a set of standard operating procedures (SOPs), but not all are being followed by team members, meaning that not all risks in the pharmacy are being properly managed. For example, there is evidence of the procedures relating to 'cold-chain medicines' and 'date-checking of dispensary stock' not being followed. And most team members have not signed the pharmacy's current SOPs to show that they have read and understood them. |
Newly appointed pharmacy manager ensuring all staff have read, signed and are working in accordance with the SOPs. New fridge thermometers have been ordered for the site. Superintendent pharmacist has set up electronic fridge temp records for both fridges using the ProScript PMR. The site will now be prompted to enter fridge temperatures each day. Newly appointed manager implemented a date-checking and cleaning rota. |
07/10/2025 | 25/11/2025 |
| 4.3 | There are out-of-date medicines in stock and some medicines are not packaged or labelled appropriately. And the pharmacy's monitoring processes are not effective in ensuring temperature sensitive medicines are held within a suitable environment . So there is a risk that medicines could be supplied which are not fit for purpose. |
Newly appointed manager implemented a date-checking and cleaning rota. Expired medicines will be removed from the shelves and destroyed. The entire dispensary will be date-checked initially and then kept up to date on a rolling basis. |
07/10/2025 | 25/11/2025 |
Pharmacy inspections
Inspection reports and learning from inspections