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Pharmacy inspections

Inspection reports and learning from inspections

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Steve's Chemist (1031172) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made

The pharmacy does not keep all its records fully in line with legal requirements.

•Implemented new procedures so ALL pharmacist hand write their details and hours into RP log.(no more use of Computer system) 15/11/20. Folder kept near main dispensing terminal.
•Lockable cabinet in use for storage of private RX/Specials.
•All colleagues to Revisit SOP ‘EMERGENCY SUPPLY AT THE REQUEST OF A PATIENT’ –record keeping, and for Private Rxs.
•CD Balance to be completed routinely.

16/12/2020 15/12/2020

The pharmacy does not always manage confidential information properly or securely dispose of confidential waste. This could result in people’s personal information being disclosed.

•Revisit Data Protection Security.
•All colleagues to undertake IG spot checks and revisit PSNC GDPR Staff training booklet.
•Each dispensing terminal has a box for confidential waste away from general waste, when 2/3 full shredded appropriately/ end of week.
•All patient information in side room will be stored away from sight,
•Planning to move the free standing wall in the stock room further out, so we can add shelves to keep rest of the multi compartment compliant packs.
•As well as assembled medicines for the delivery driver.
•This will ensure no confidential information will be seen by other patients and the consultation room would be clear for other service use.

16/12/2020 15/12/2020

The pharmacy does not adequately identify or manage the risks associated with selling codeine linctus over the counter. It has been purchasing and selling large amounts of codeine linctus. The pharmacy does not have the appropriate governance in place to manage this situation. And there are no documented details about the action it has taken to ensure medicines which are addictive, can be abused and misused are sold safely. This means people's health is at risk.


The pharmacy is not selling codeine linctus safely. It does not have any systems in place or audit trails to identify, monitor and review sales of this medicine.


Not all team members do the relevant accredited training for the tasks that they carry out.

Co-owners to be put on the NPA programme from 2/12/20

Implementation of Training time set aside twice a month with SI for update or necessary training.

16/12/2020 15/12/2020

The premises are not maintained to an appropriate level of hygiene for some of the services provided.

•Deep clean was conducted, clearing any irrelevant material from dispensary and side room 16/11/20
•Clutter free work stations
•Cleaning Rota placed for daily review near sink.

04/01/2021 02/12/2020

There are significant tripping hazards in the dispensary which presents a risk to staff.

•Dispensary floor was changed on the weekend of 21/22nd November.
•New sink fitted to provide extra space in dispensary.
•Patent facing counter brought forward for extra room to store completed prescriptions, and stored out of view.

01/03/2021 02/12/2020

The pharmacy is purchasing and selling excessive amounts of codeine linctus without the appropriate safeguards in place to prevent its misuse and abuse.


The pharmacy does not always store patient-returned medicines separately from its current stock medicines. Not all its stock medicines are packaged or labelled appropriately. And it does not always appropriately restrict access to some medicines which require additional security measures.

•All colleagues revisited
•PSNC COVID-19 Dealing with patient returns, Appendix 1 checklist.

•Reinforces with all colleagues to store split packs accordingly. When using for a prescription original container should be kept with pharmacy, and plain carton/pack given to patient should include batch number and expiry date. Each brand/batch kept in its own original box/container.

•Briefed all pharmacists on CD key protocol and introduced procedure for end of day.

16/12/2020 15/12/2020