| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy had obtained new standard operating procedures. But they were a draft version which had not been updated to ensure the details reflect the actual processes that are carried out. The pharmacy operates using locum pharmacists who rely upon written procedures to ensure they deliver safe and effective care. So the pharmacy may not be able to demonstrate how it suitably manages the risks associated with providing pharmacy services and how members of the pharmacy team fully understand what is expected of them. |
Numark sops downloaded and signed |
16/10/2025 | 17/09/2025 |
| 1.2 | The pharmacy team generally discuss mistakes that are identified. But the pharmacy team do not routinely record their mistakes so they can review and look for underlying trends. An example of an error which was reported by the superintendent pharmacist had not been discussed with the rest of the team. So the pharmacy is unable to demonstrate how it learns from errors, and show what action is taken to reduce the risk of similar mistakes happening again. |
Mistakes recorded in near miss book and reviewed |
16/10/2025 | 17/09/2025 |
| 4.2 | The pharmacy has a substance misuse service which is provided by the responsible pharmacist on duty. But it does not have sufficient systems in place to ensure the risks associated with service are adequately addressed. This includes using multiple team members to check each other’s work, having robust records to show who had or had not collected their medication, and managing the risk of relying on a different pharmacists each day to provide the service. There have also been examples of incidents related to this service. In the absence of having sufficient systems in place the pharmacy is unable to demonstrate this service is safe and effective. |
New SOPs in place, which include: 1. when giving out meds check name also when pouring somebody check quantity. |
16/10/2025 | 17/09/2025 |
| 4.3 | The pharmacy does not have sufficient processes to monitor fridge temperatures to ensure medicines that require cold conditions are always stored within their required temperature range. This has led to some medicines being stored outside of their required temperature range without action being taken. So the pharmacy is unable to show medicines are always fit for purpose. |
Recording all fridge temp in diary. |
16/10/2025 | 17/09/2025 |
Pharmacy inspections
Inspection reports and learning from inspections