| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.8 | The pharmacy team members do not demonstrate an appropriate knowledge of safeguarding and do not know what to do if a vulnerable person presents in the pharmacy. So, team members may miss opportunities to support vulnerable people. |
All staff will be asked to read and sign the Standard Operating Procedure SOP on safeguarding again to reinforce awareness and responsibilities. The contact details for the local safeguarding team have been printed and prominently displayed in the dispensary for easy reference. All staffs will complete the CPPE safeguarding training by 15-10-2025 to ensure they are competent in identifying and responding to safeguarding concerns. |
27/10/2025 | 25/10/2025 |
| 2.4 | There is no evidence that any ongoing training or learning routinely takes place at the pharmacy. So, team members may be missing out on important opportunities to learn about any new medicines, services or changes the pharmacy is introducing. |
Make a folder to keep copies of documents provided for any training given to team members. |
27/10/2025 | 25/10/2025 |
| 2.2 | Pharmacy team members have not completed the appropriate training for their roles with an accredited training provider. One team member has not been enrolled on a course and has been working for the pharmacy for over three months. And another team member started training and subsequently paused this and has not been restarted on a training course. So, team members may not have the required knowledge and skills to work safely and efficiently in the pharmacy. |
Head office is currently liaising with Buttercups and Skills4Pharmacy to address the training gaps. The Head of Operations has confirmed that, by the first week of October, all staffs will be registered on the appropriate courses according to the business needs. |
27/10/2025 | 25/10/2025 |
| 4.4 | The pharmacy cannot demonstrate that it is able to appropriately receive and action safety alerts and recalls of medicines and medical devices. During the inspection, the team could not provide any evidence to show that alerts were being received in the pharmacy and team members did not know how to action safety alerts and recalls. So, there is a risk that safety alerts and recalls are not being actioned appropriately or in a timely manner. This increases the risk that people receive a medicine or medical device that is not fit for purpose. |
Go through safety alerts and recalls with all team members to ensure they understand the procedures. Staffs have been instructed to check emails and messages from head office regularly. Any MHRA alerts or local alerts from the Integrated Care Board (ICB) should be printed and acted upon immediately. The person completing the action must sign to confirm completion. Procedures for handling alerts should include guidance for when locums are working in the pharmacy. |
27/10/2025 | 25/10/2025 |
Pharmacy inspections
Inspection reports and learning from inspections