| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy is not fully managing the risks associated with its premises. And it has not sustained the improvements that it had made previously to address these risks. The dispensary is poorly organised, and not all medicines are stored appropriately. The pharmacy does not manage its pharmaceutical waste in line with its contractual obligations, increasing significant risk to public health and the environment. Not all parts of the premises are kept in a clean and tidy condition. And the pharmacy does not keep all of its records in line with requirements. Its team members are undertaking tasks that they should not be undertaking in the absence of a Responsible Pharmacist. |
New dispensary layout and work flow to be implemented All pharmaceutical waste has now been collected by Stericycle. Going forward all pharmaceutical waste will be collected in a timely manner. Cleaning rota will be more detailed to ensure all areas are covered. New RP log has been installed on PMR to make the register easier to access. |
13/08/2025 | 13/08/2025 |
| 1.6 | The pharmacy is not keeping its Responsible Pharmacist (RP) records and controlled drug (CD) records in line with requirements. Discrepancies of controlled drugs are not investigated, corrected or reported to the CD Accountable Officer where the discrepancy cannot be resolved. |
RP recording has been moved to the PMR to enable easy access. All CD balances are now carried out weekly. |
30/07/2025 | 13/08/2025 |
| 1.3 | The pharmacy has weak governance and it does not have sufficiently robust systems in place to ensure team members understand and adhere to restrictions on permitted activity when there is no Responsible Pharmacist present. There was evidence found during the inspection that medicines had been handed out in the pharmacist's absence. |
Weekly Team meetings have been held and will continue to be held regularly to remind everyone of the RP regulations CPPE e-assesemnt module on RP will be completed by all the team. |
30/07/2025 | 13/08/2025 |
| 3.1 | The dispensary is very cramped and cluttered. This is impacting the overall efficiency of the dispensing process. And it may increase the risk of dispensing mistakes or accidents. |
Decluttering of the dispensary with more dispensary space created by extending more into the shop space. |
13/08/2025 | 13/08/2025 |
| 3.3 | The premises are not maintained to a level of hygiene appropriate to the pharmacy services provided. |
Cleaning rota will be more detailed to ensure all areas are covered. |
13/08/2025 | 13/08/2025 |
| 4.3 | The pharmacy is not managing its pharmaceutical waste safely. It has accumulated significant quantities of waste medicines which increases health and safety risks. And it does not always store its stock medicines appropriately. This increases the chance that mistakes could be made. The pharmacy's controlled drug cabinet is not fit for purpose. It is cramped and it does not have enough space to accommodate the stock the pharmacy carries safely. |
Pharmaceutical waste has all been collected now. New, additional Controlled Drug cabinet has been acquired enabling better organisation of stock. |
13/08/2025 | 13/08/2025 |
| 4.2 | The pharmacy does not manage its services safely and effectively. Staff are not working in accordance with the pharmacy's Standard Operating Procedures. Medicines are handed out in the absence of Responsible Pharmacist. The dispensary is very disorganised and cramped. There is insufficient storage space to store medicines safely. |
Weekly Team meetings have been held and will continue to be to remind everyone of the RP regulations CPPE e-assesemnt module on RP will be completed by all the team. Dispensary has been extended more into the previous shop space. |
13/08/2025 | 13/08/2025 |
Pharmacy inspections
Inspection reports and learning from inspections