| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy provides some services under an informal arrangement with local services or independent prescribers. For example, it delivers higher risk medicines to a local accommodation for vulnerable people. The pharmacy also dispenses weight loss medicines against prescriptions written by a nurse prescriber, but the pharmacy does not know if the prescriber operates under a CQC registered service. And the pharmacy has not undertaken any further due diligence checks or completed a risk assessment. So it cannot demonstrate all of the risks have been identified, and suitably managed. |
A Risk assessment has been carried out by the pharmacist manager regarding delivery of high risk medications to the local accommodation and this is documented and kept in a file on premises. This will be regularly reviewed annually. The risk assessment is attached. Checks have now been made regarding cqc registration of nurse prescribers for wight loss medications and where necessary supply has been stopped, |
08/01/2026 | 08/01/2026 |
| 1.6 | The pharmacy has some records, but they are incomplete. The records for the responsible pharmacist are made across two different electronic systems, and the pharmacy had not identified some missing entries. This means the pharmacy may not be able to accurately show when a pharmacist was present. And its private prescription register does not always contain the details of who prescribed the medicines, so it may not be able to respond effectively to a query or concern. |
All pharmacists and staff have been made aware once again to use pharmsmart software for all logs and this will be closely monitored by the pharmacist manager and superintendent. |
08/01/2026 | 08/01/2026 |
| 4.3 | The pharmacy stores its refrigerated medicines in three different fridges. But one of the fridges does not contain a thermometer, so the pharmacy cannot demonstrate the medicines are stored at the correct temperature to help make sure they remain safe to use. |
A new pharmacy fridge is being bought with thermometer to ensure all fridge products can be kept in the correct temperature range at all times and documented on pharmsmart. |
08/01/2026 | 08/01/2026 |
| 4.3 | The pharmacy correctly disposes of unwanted medicines in DOOP bins, which are collected by a licensed waster carrier. But the bins are not stored securely away from unauthorised access. |
The bins are now stored in a lockable cupboard room to prevent any unauthorised access. |
08/01/2026 | 08/01/2026 |
| 5.2 | The pharmacy had access to some glass conical measures, which were stamped to show they were of a sufficient calibration grade. But they did not have a measure for 10ml or less, and they used oral liquid syringes which do not provide a sufficient grade for medicines which require reconstitution or are considered higher risk. |
New concial measures have already been ordered with smaller measuring sizes of 10ml and less. |
08/01/2026 | 08/01/2026 |