Amy Pharma Ltd (1040377) - Improvement action plan

The pharmacy has medicines which require secure storage, but it does not always store them in a legally compliant way. This increases the risk that these medicines may be lost or diverted.

The expired Controlled Drugs have now been destroyed by an authorised person. Sufficient space has been restored in the Controlled Drug cabinet, and all stock is securely stored. Going forward, expired stock will continue to be separated and destroyed promptly without delay to maintain full compliance with legal storage requirements.

The pharmacy makes entries about certain medicines which require additional records to be made. But several of these records are incomplete and some do not contain the status of the person collecting the medicine. One record seen is not dated, and another has been crossed out. Some expired stock had been entered out of the register before it had been appropriately destroyed. And the pharmacy does not regularly audit the running balances for these medicines, and some balance discrepancies were found during the inspection. Taken together, this makes it harder for the pharmacy to properly account for these medicines.

Following the inspection, we have improved our Controlled Drug (CD) record-keeping procedures to ensure all entries are completed accurately and at the time of receipt and supply. All required information, including the date and the status of the person collecting the medicine where applicable, is now recorded. Staff have been reminded not to cross out errors; instead, any mistakes will be corrected by making a clear note while keeping the original entry visible to maintain a full audit trail. Expired Controlled Drugs will be clearly recorded with the medicine name, quantity, and date, and stored separately in the CD cupboard until they are appropriately destroyed. They will only be removed from the CD register once destruction has taken place. Monthly running balance checks and regular CD audits have also been introduced to identify and investigate any discrepancies promptly, ensuring Controlled Drugs are accurately accounted for and managed in line with GPhC standards.