| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.3 | Pharmacy team members undertake tasks including hand out of assembled bags of medicines without a responsible pharmacist (RP) signed-in and present. They are unclear about the difference between RP absence and not having a RP signed-in, and about what tasks they can undertake in each scenario. |
Responsible Pharmacist compliance: All team members will receive mandatory training to ensure full understanding of the legal and operational requirements relating to the RP sign-in, presence, and permitted activities in their absence. Clear written guidance will be displayed in the dispensary, and no assembled medicines will be handed out without a responsible pharmacist signed in and present. Standard operating procedures (SOPs): SOPs have been reviewed and reinforced with the team, particular focus on roles, responsibilities, and escalation processes. Staff competency will be assessed and documented to ensure full compliance. |
21/05/2026 | 27/05/2026 |
| 4.3 | The pharmacy does not monitor the operating temperature of its fridges to ensure its cold chain medicines are kept within the storage conditions indicated by the manufacturer. And it does not follow safe processes to dispose of waste medicines and reduce the risk of unauthorised access to them following vaccination clinics. |
Fridge temperature and monitoring: We are ensuring fridge temperatures are recorded indefinitely twice daily on our pmr system, whilst also making sure that all cold chain medications are stored within manufacturer-recommended ranges. Any discrepancies will be managed with SOP protocols. Safe disposal of medicines: We have introduced stricter controls for the handling and disposal of waste medicines, particularly during vaccination clinics. This includes secure storage, restricted access, and clear accountability to prevent the waste of medicines and unauthorised access. Ongoing Oversight and auditing: Regular internal audits will be conducted to monitor adherence to these improvements, with accountability assigned to ensure sustained compliance and continuous improvement. |
21/05/2026 | 26/05/2026 |
Pharmacy inspections
Inspection reports and learning from inspections