City Pharmacy Ltd (1034091) - Improvement action plan

The pharmacy is not able to show that it has processes in place to adequately review and monitor the safety and quality of the services it provides. For example, the pharmacy could not show that its team were aware of and were always following its written procedures about dealing with dispensing mistakes. And the pharmacy had very limited records about near misses (only one event per year had been recorded in 2024 and 2025). This meant it could not show that near misses were used routinely as opportunities to identify improvements in the pharmacy’s ways of working.

All SOPs relating to dispensing errors and near misses will be reviewed and updated for clarity. All staff will be trained on these updated procedures and required to sign to confirm their understanding and compliance. We are implementing a new near-miss log and encouraging staff to record all incidents consistently. These records will be reviewed regularly to identify trends, improve working practices, and monitor reporting through team discussions. The staff will adopt visual aids such as Look-Alike, Sound Alike (LASA) in the dispensary where appropriate.

The pharmacy is not able to show that it has processes in place to adequately review and monitor the safety and quality of the services it provides. For example, the pharmacy could not show that its team were aware of and were always following its written procedures about dealing with dispensing mistakes. And the pharmacy had very limited records about near misses (only one event per year had been recorded in 2024 and 2025). This meant it could not show that near misses were used routinely as opportunities to identify improvements in the pharmacy’s ways of working.

All SOPs relating to dispensing errors and near misses will be reviewed and updated for clarity. All staff will be trained on these updated procedures and required to sign to confirm their understanding and compliance. We are implementing a new near-miss log and encouraging staff to record all incidents consistently. These records will be reviewed regularly to identify trends, improve working practices, and monitor reporting through team discussions. The staff will adopt visual aids such as Look-Alike, Sound Alike (LASA) in the dispensary where appropriate.

Although most medicines are stored in appropriate conditions some medicines are not all stored safely and access to them is not securely managed.

Review the SOPs for Controlled Drugs management, including ordering, receipt, storage and disposal. All the staff are to undergo retraining on these CD storage procedures. This is to cover legal requirements such as storing CDs in dedicated locked cabinets and key management responsibilities allocated to the Responsible Pharmacist.

Although most medicines are stored in appropriate conditions some medicines are not all stored safely and access to them is not securely managed.

Review the SOPs for Controlled Drugs management, including ordering, receipt, storage and disposal. All the staff are to undergo retraining on these CD storage procedures. This is to cover legal requirements such as storing CDs in dedicated locked cabinets and key management responsibilities allocated to the Responsible Pharmacist.

Although most medicines are suitably stored some equipment used to store some medicines that require secure storage is faulty and requires repair.

The Controlled Drug cabinet and the key and lock mechanism to be reviewed immediately to comply with the misuse of drugs regulations. The lock to comply with the thief resistant standards. Self inspection of the CD cabinet and lock to be done by the pharmacy staff every 3 months.