| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy's responsible pharmacy (RP) record is inaccurate, and the pharmacy is not able to provide a reliable record of the times there has been an RP on the premises. Private prescriptions for controlled drugs (CDs) are not submitted to the relevant authority in a timely manner to ensure compliance with requirements. |
• All pharmacists will make the RP record contemporaneously when responsibility is assumed and will accurately record any absence, return and end of responsibility. Records will not be pre-signed or reconstructed retrospectively unless supported by reliable contemporaneous evidence; any correction will be dated, signed and auditable. The locum induction checklist will include this requirement. • The Pharmacy Manager will review the RP record each working day for completeness. The Superintendent/Compliance team will audit it weekly for eight weeks and monthly thereafter, documenting findings and corrective action. • All outstanding private Schedule 1, 2 and 3 CD prescriptions and requisitions will be reconciled and submitted immediately using the correct FP34PCD process. Going forward, original forms will be logged and submitted separately to NHSBSA no later than the fifth day of the following month. • A monthly CD submission log and calendar reminder will record the date supplied, submission month, date sent, second-person check and proof of posting. The RP or Pharmacy Manager will confirm completion, with central compliance oversight. |
12/08/2026 | 21/08/2026 |
| 1.1 | Members of the pharmacy team do not have a clear understanding of the pharmacy’s procedure for operating in the absence of the responsible pharmacist. They are not clear what activities must not take place when the responsible pharmacist is absent, and pharmacy services are sometimes provided in a way that may put patient safety at risk. |
• The Responsible Pharmacist (RP) and RP absence procedures will be reviewed, approved by the Superintendent Pharmacist and implemented. They will clearly distinguish between: (a) no RP having assumed responsibility and signed in, when no Pharmacy (P) medicines or prescriptions may be supplied; and (b) a temporary absence after an RP has assumed responsibility. * An RP absence risk assessment and a one-page quick reference guide will be displayed in the dispensary, listing permitted and prohibited activities, escalation arrangements and key contacts. • During a temporary absence, checked-and-bagged medicines will only be handed out where a pharmacist has specifically authorised a trained and competent team member and the item requires no further pharmacist intervention. OTC sales of P medicines will not take place while the pharmacist is absent. • All permanent, relief and locum staff will receive a documented briefing, read and sign the revised procedures, and complete a short knowledge/competency check. Compliance will be reviewed weekly for eight weeks and monthly thereafter. |
12/08/2026 | 21/08/2026 |
| 1.3 | Pharmacy team members do not always work within the limitations of their roles. For example, pharmacy team members sometimes sell Pharmacy (P) medicines and hand out prescriptions when the responsible pharmacist is absent without having the proper authority or a clearly defined framework permitting this. |
* A written roles and authority matrix will define the tasks each team member may undertake according to their qualification, training, competence and current authorisation. • Only named team members who have completed training and a competency assessment may be authorised to hand out checked-and-bagged prescriptions. Each authorisation will be recorded on the pharmacy authorisation log, including the pharmacist’s name and GPhC number, absence duration, reason, names of authorised staff and pharmacist signature. • The SOP will require staff to withhold supply and contact the pharmacist whenever an item or scenario needs pharmacist intervention, including a clinical query, counselling, a new or changed medicine, a controlled drug, a refrigerated item, an instalment supply, a higher risk medicine or any uncertainty. • P medicines requested for OTC sale will not be sold while the pharmacist is absent. The Pharmacy Manager will complete weekly observed checks and retain signed training and competency records. Any breach will be escalated immediately to the Superintendent Pharmacist. |
12/08/2026 | 21/08/2026 |
Pharmacy inspections
Inspection reports and learning from inspections