| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | The pharmacy stores most medicines in appropriate conditions. But it is unable to demonstrate that all of its medicines that require cold storage are stored between 2 and 8 degrees Celsius. |
Digital min/max thermometers have been installed/replaced in all supplementary fridges used to store medicines. Temperatures will be checked and recorded daily, with staff trained on correctly reading, resetting and documenting temperatures and taking appropriate action if outside 2–8°C |
28/10/2026 | 27/10/2026 |
| 4.3 | Most medicines are stored appropriately in their original containers. But the pharmacy sometimes removes medicines from their original blister packaging and stores them loosely when assembling compliance packs. This means the pharmacy cannot be sure that these medicines are being stored in the right conditions to preserve their efficacy. And increases the risk of a mistake being made. |
The Compliance Pack (MDS) process has been reviewed and staff retrained. Medicines will remain in their original packaging/blisters until required for assembly and any part-used stock will be returned to its correctly labelled original packaging immediately after use. Loose medicines will not be stored for future MDS assembly. |
28/10/2026 | 27/10/2026 |
| 1.6 | The pharmacy does not have a register available to team members to record medicines returned by people which require safe storage. And it does not complete regular checks of stock medicines requiring safe storage against the quantities maintained in its registers. So there is a risk that discrepancies may not be resolved effectively. |
A patient-returned CD register was in place and will now be kept in an agreed accessible location so all pharmacists, locums and relevant staff are aware of it and can make the required entries. CD register balances will also be checked and documented every 4 weeks, with any discrepancies investigated and resolved promptly. |
28/10/2026 | 27/10/2026 |
Pharmacy inspections
Inspection reports and learning from inspections