| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 2.4 | The pharmacy doesn’t provide team members with opportunities to discuss issues or training needs. For example, there are no regular team meeting or staff reviews. And team members do not always feel confident raising concerns or talking about mistakes. This results in poor communication and means team members are not kept up to date about the operation of the pharmacy, and opportunities for improvement may be missed. |
Weekly team huddles will be introduced to provide a structured and regular opportunity for staff to discuss ongoing challenges, training requirements, workload, and any support needed. These meetings will also include time to reflect on near misses and dispensing incidents, with a focus on shared learning and continuous improvement. A clear whistleblowing procedure will be put in place and communicated to all staff, ensuring they understand how to report concerns confidentially and without fear of reprisal. Staff reviews and one-to-one check-ins will also be scheduled regularly to ensure individual needs, training goals, and professional development are supported. These actions aim to create a more engaged, informed, and supported team environment, helping us improve communication, safety, |
29/08/2025 | 01/09/2025 |
| 4.2 | The pharmacy doesn’t always keep appropriate audit trails for changes to medication in compliance aid packs. It does not routinely record the date of medication changes or correspondence with the prescriber which could cause confusion in the event of a query. The packs are not always supplied with packaging leaflets or labelled with appropriate cautionary and advisory labels. So, people might not have easy access to all of the information they need to take their medicines safely. |
All interventions and medication changes will be clearly documented on the patient’s PMR (Patient Medication Record) to ensure an accurate audit trail is maintained. Medication discontinuation notes and any We will ensure that patient information In addition, we will review and update the relevant SOPs to reflect these changes and ensure that all staff are trained to follow the correct procedures consistently. These actions will help ensure safe dispensing practices, better communication, improved record-keeping, and that patients receive all necessary information to take their medicines safely. |
29/08/2025 | 01/09/2025 |
Pharmacy inspections
Inspection reports and learning from inspections