| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has written standard operating procedures. But these have not been updated for several years and there are no records to show when they were last read by members of the team. And the procedures do not cover all aspects of the pharmacy's services. So the SOPs may not always reflect current practice and team members may not always fully understand what is expected of them. |
The superintendent is reviewing the SOPs and updating them where needed. |
14/04/2025 | 26/04/2025 |
| 1.6 | The pharmacy has not recorded the supplies of medicines it made against private prescriptions during January 2025. So it is not able to provide all of the required information in relation about the supplies that were made. |
The pharmacy team will ensure records of private prescriptions are kept up to date. |
14/04/2025 | 26/04/2025 |
| 1.2 | The pharmacy team discuss mistakes when they occur. But the pharmacy team are unable to show how they record mistakes so they can review and look for underlying trends. So there is a risk some mistakes may be overlooked and the same or similar mistake may happen again. |
As part of reviewing the SOPs, the superintendent is reviewing their near miss process and updating the SOP and process where needed. |
14/04/2025 | 26/04/2025 |
| 4.3 | The pharmacy does not adequately manage its medicines to ensure they are always stored correctly or fit for purpose. Some medicines that need cold storage are not appropriately monitored to make sure they are being kept at the right temperature. Liquid medicines do not always have the date of opening written on, including those with a shelf-life of 4 weeks once opened. So members of the team may not know whether they are still suitable for use. Medicines which have expired are not stored in medicine waste bins to ensure they are disposed of correctly. Some medicines are stored in loose blister strips that have been removed from their original containers, which could increase the risk of errors. |
Fridge temperatures will be checked on a regular basis to ensure the fridge medicines are stored at the correct temperature. And temperatures will be recorded. Liquid medicines are being checked, and destroyed if necessary. Expired medicines will be stored in DOOP bins. Loose blister strips of medicines will be removed from the shelves, and stored in correctly labelled containers, or placed in the DOOP bin if necessary. |
14/04/2025 | 26/04/2025 |
Pharmacy inspections
Inspection reports and learning from inspections