| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy has written processes available to make relevant records when mistakes are identified. However, pharmacy team do not routinely record mistakes that happen and so may not be to review and learn from common mistakes. And there is evidence that mistakes are not always recorded when highlighted to the members of the pharmacy team. |
Cornwell’s Chemists uses Pharmapod software for reporting errors and for electronic versions of all PGD’s, which it is expected that all members of staff use routinely to record errors and near misses. A monthly safety report will be compiled, and where practical members of staff will attend a briefing to discuss these. Staff who cannot attend will be required to read the report and sign the report. SOP 22 Covers the recording of dispensing Errors and near misses. All staff have been required to re-read all Sop’s. |
14/11/2025 | 17/11/2025 |
| 1.6 | Records for higher-risk medicines are not well maintained. The pharmacy does not regularly audit stock levels of these medicines and, as a result, the pharmacy delays identifying and managing discrepancies which have occurred. |
It was found that weekly CD balance checks were not carried out as expected and there were several discrepancies. This was rectified immediately, and it can be evidenced that all controlled drugs registers are correct and are now checked weekly . This is evidenced using CDRx software. All patient returns are dealt with promptly. |
31/10/2025 | 17/11/2025 |
| 4.3 | The pharmacy team regularly checks the expiry dates of the medicines but does not keep corresponding records of these checks. So, some stock may be overlooked and there is evidence that expired medicines have been inadvertently supplied. The pharmacy does not regularly record the fridge temperatures and so may not be able to demonstrate that it stores cold chain medicines appropriately, so they remain safe to supply to people. |
The whole dispensary has been date checked and cleaned, and records are available for inspection. There are two methods of recording which the branch can use. The first is a paper copy included in SOP28, the second method is an electronic template available in the software CDRx. The Fridge temperature sheets were found after the inspection visit, however there were gaps in reporting, therefore, a more robust method was required. A new system for recording fridge temperatures has been implemented using our Titan PMR for all branches, which can be checked by head office. Titan will remind staff to record fridge temperatures at several times of the day if a recording has not been made. |
31/10/2025 | 17/11/2025 |
Pharmacy inspections
Inspection reports and learning from inspections