| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have effective governance procedures in place. Some standard operating procedures are outdated which means they do not reflect the processes the team are working to. And some of the written procedures are not readily available. This means the pharmacy cannot demonstrate that its governance systems are up to date and consistently support the safe running of the pharmacy. |
All the sops will be reviewed against current pharmacy sops. Outdated sops will be updated or replaced and current sops will be readily available for all the team members. A master index will be introduced. Staff will be required to read the sops and sign staff acknowledgment records. It will be reviewed and kept under review so procedures remain current and reflect the way the pharmacy operates. |
21/09/2026 | |
| 1.2 | The pharmacy does not have effective systems to identify and learn from mistakes. Dispensing errors and near miss incidents are not routinely recorded or reviewed, and learning is not consistently shared with members of the team. This means the pharmacy cannot demonstrate that it is effectively identifying risks and taking action to help prevent similar mistakes in the future. |
A system for recording dispensing errors and near misses will be introduced and more importantly enforced. Near misses and errors will be recorded at the time they occur and be reviewed for any patterns and contributory factors, they will be discussed with the team so learning and preventative actions are shared. Recurring risks such as lasa, high risk meds will be identified and acted upon. Records of reviews, learning and actions will be taken will be kept as evidence. |
21/09/2026 | |
| 1.6 | The pharmacy does not maintain the records it needs to in line with requirements. Records for the responsible pharmacist are incomplete, records for private prescriptions are not always accurate, and records for unlicensed medicines are not readily available. In addition, some records for higher-risk medicines are incomplete and stock balances are not routinely checked, which has led to discrepancies. This means the pharmacy may not be able to appropriately respond to any concerns or queries regarding the services it provides. |
Required pharmacy records will be reviewed and brought up to date. Responsible Pharmacist records will be completed accurately and contemporaneously. Private prescription records and records relating to unlicensed medicines will be checked for completeness and accuracy and maintained so they are readily retrievable. Records and stock balances for higher-risk medicines will be checked routinely, discrepancies will be investigated promptly and corrective action will be documented. Staff responsibilities for completing and checking these records will be reinforced. |
21/09/2026 | |
| 4.3 | The pharmacy does not consistently manage medicines safely in line with its procedures. It does not have an effective date checking system, fridge temperature monitoring is not routinely completed, and no action is taken when temperatures are outside the required range. Higher-risk medicines are not always stored securely and returned medicines are not always separated and clearly managed. This means the pharmacy cannot demonstrate that the medicines it supplies are always safe and appropriate for people to use. |
A structured date-checking system will be introduced and reinforced, with checks documented and short-dated stock identified and managed. Fridge temperatures will be recorded every working day and any reading outside the required range will be investigated and action documented before affected stock is supplied. Higher-risk medicines will be stored securely in accordance with pharmacy procedures. Returned medicines will be clearly separated from usable stock and placed in the appropriate designated area for safe disposal. Storage areas will be reviewed, including separation of LASA medicines where identified as a risk, and ongoing checks will be recorded. |
21/09/2026 |
Pharmacy inspections
Inspection reports and learning from inspections