| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 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. |
A full review of all statutory record-keeping processes has been completed. Responsible Pharmacist records have been reviewed and staff retrained to ensure records are completed accurately at the start and end of each RP period. ( Record Recorded on PMR system and reviewed weekly on a Monday. Joel) Private prescription recording procedures have been updated and are now checked on entry for completeness.( Private Register on PMR system) A dedicated unlicensed medicines register has been implemented and kept on site. (SOP updated and all staff aware of correct processes) Controlled Drug registers and higher-risk medicine records have been audited, discrepancies investigated and stock balances reconciled. Daily stock balance checks for CDs dispensed that day have been introduced alongside a 2weekly full CD audit. SOPs relating to statutory records have been updated and all staff have received documented training. |
31/08/2026 | 17/08/2026 |
| 4.3 | The pharmacy does not consistently manage medicines safely in line with its procedures. It does not always keep appropriate records of date checking the expiry dates of its stock medicines, which has resulted in out-of-date medicines not being removed from the dispensary shelves. Opened liquid medicines are not always labelled with a date of opening, and fridge temperature monitoring is not consistently completed. This means the pharmacy cannot demonstrate that the medicines it supplies are always safe and appropriate for people to use. |
A complete dispensary stock audit has been undertaken and all expired medicines removed from stock and any short dated stock highlighted. We removed all stock within a 3month expiry date. A documented date-checking programme has been introduced, dividing the dispensary into designated sections with scheduled three monthly checks and signed records.(using online software) Opening dates are now recorded on all liquid medicines immediately upon first use using pharmacy labels. Fridge temperature monitoring has been reinforced with daily documented checks and escalation procedures where readings fall outside acceptable limits. (Recorded on online software) SOPs covering date checking, storage of medicines and fridge monitoring have been reviewed and all staff have completed retraining. Compliance will be monitored through regular weekly audits on the online software application. |
31/08/2026 | 17/08/2026 |
Pharmacy inspections
Inspection reports and learning from inspections