| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | The pharmacy stores pharmacy only (P) medicines including high risk P medicines in the shop floor area in clear boxes areas where there is a risk of unauthorised access and/or theft. And the team is not aware of any risk assessments having been completed for this. So, the pharmacy cannot demonstrate that it stores P medicines safely or appropriately. |
The Pharmacy and Numark Merchandising team carried out a risk assessment prior to approving the layout and implementing them. The new layout has positive benefits to the Patients and customers through better interactions with staff prior to selection, picking and paying for the items. The layout has been in place for a very short period, and we are constantly evaluating and making changes to locations, so it is work in progress and we are always making adaptations to get the best for patient safety. |
17/07/2026 | 15/07/2026 |
| 1.7 | The pharmacy stores some checked medicines awaiting collection with people's details on them in an area of the dispensary near the entrance to the consultation room where team members have conversations with people. So, there is a risk of people's confidential information being exposed. |
The area in question is the shelving in front of the consultation room behind the confidential counter area where some form of privacy is given to Patients’ who so desire but not necessarily in the consultation room. We are going to get special plastic boxes to put the checked items in so that no Patient data is visible to Customers. |
17/07/2026 | 15/07/2026 |
| 1.2 | The pharmacy team does not record near misses (mistakes that occur before a medicine leaves the pharmacy). And the team members are not completely sure how or if dispensing errors (mistakes spotted after a medicine has left the pharmacy) are recorded. So, team the pharmacy cannot show how it learns from things that go wrong. |
The team has been asked to make regular recording of near misses on Proscript as the last record was made back in May 2025. I have personally done a refresher training on this with the Responsible Pharmacists and the ACT and Apprentice. Near misses will be recorded on Proscript and items that have left the Pharmacy with a dispensing error will be recorded as incident reporting on Proscript as well. I will supervise this personally to make sure it is done routinely and imprinted in our practice. |
17/07/2026 | 15/07/2026 |
| 1.6 | The pharmacy keeps running balances for certain medicines which require additional records. But it does not investigate discrepancies found between the running balance and the quantity in stock in a timely way. And the pharmacy cannot demonstrate that it records entries within the required timeframe. This means that the pharmacy is less able to promptly identify if any mistakes have been made or any stock has been lost. |
Discrepancies in the running balances need to be investigated and reconciliation made as soon as it is detected. The Pharmacy will assign a member of staff to check balances once a month and any discrepancies detected will be investigated and resolved as quickly as detected to keep the balances right. Pharmacists and Locums will be asked to adhere to our operational procedures of making entries to registers as soon as possible after these items are handed to them by the delivery drivers. Record of supply will also be made within the working day of supplying the items to the Patients. |
17/07/2026 | 15/07/2026 |
Pharmacy inspections
Inspection reports and learning from inspections