| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy does not always keep appropriate records for its services using Patient Group Directions. A few vaccination records showed they were administered by a different team member to the one who actually administered them. |
Raised with software provider to make site selection mandatory. SOPs updated and staff rebriefed. |
04/12/2025 | 15/12/2025 |
| 4.2 | The pharmacy administers vaccinations under the National Protocol, but it does not always follow it. People coming for vaccines are not always assessed by a healthcare professional prior to vaccination. |
Reinforce staff training on detailed narratives and trend analysis through quarterly reviews. |
04/12/2025 | 15/12/2025 |
| 4.2 | The pharmacy cannot demonstrate that it gathers adequate information before making supplies of medicines to people or that it acts on the information it gathers during consultations to support people’s health. Several records about supplies of weight-loss medicines showed that the person had a raised blood pressure reading at the time of the consultation. But there was no record to show the person had been referred to their GP for further investigation. Or if they had an existing diagnosis of hypertension and the treatment they were taking. The person's medical history was also not documented. |
Retrain vaccinators, reissue SOP, and ensure signed staff acknowledgements. |
04/12/2025 | 15/12/2025 |