| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have written standard operating procedures (SOPs) for team members to refer to. This means team members may not always be working in the most safe and effective way. |
SOPs were being updated and therefore were not on the pharmacy premises. They are now back on the pharmacy site and available for all staff. They have been updated and signed. |
10/03/2025 | 21/02/2025 |
| 1.2 | Team members do not record mistakes they make and they do not always review the mistakes to identify improvements. This means they cannot demonstrate any learnings from these events to help prevent similar mistakes happening again. |
The error/near miss log is located in the SOP file and therefore was not on site. Copies of the near miss/error chart are to be kept in the dispensary out of the file. |
10/03/2025 | 21/02/2025 |
| 1.7 | The pharmacy does not follow suitably robust processes to dispose of confidential waste. This means it cannot show that personal information is adequately protected against inadvertent disclosure. |
Shredder has been fitted into the dispensary to ensure confidential waste can be shredded adequately. |
10/03/2025 | 21/02/2025 |
| 3.2 | The consultation room is cluttered and there is confidential information accessible to people in the room. In its current state, it is not a suitable space for providing pharmacy services. |
The consultation room is being locked. Confidential information has been cleared from the room. Files have been locked in the cabinet and any bags with identifiable data have been moved into the dispensary. |
10/03/2025 | 21/02/2025 |
| 3.1 | Some areas of the pharmacy are cluttered, dirty and in a poor state of repair. This increases the risk that services are not offered safely and effectively. |
The cleaning matrix has been put up to ensure that the floors are vacuumed more frequently and the shelves are cleaned along side date checking stock. This is underway. |
10/03/2025 | 21/02/2025 |
| 4.3 | The pharmacy does not always store its medicines appropriately. It cannot show that all medicines requiring refrigeration are always stored at the right temperature. And it does not have a robust process for checking the expiry dates of its medicines to ensure medicines due to expire are separated from in-date stock. This increases the chances that medicines are supplied to people that are not suitable for use. |
The fridge within the consultation room has been reset to ensure the range is between 2 and 8C. A separate log has been created called 'consultation room fridge' from 20/02/2025 to ensure this is logged alongside the dispensary fridge temperature log. |
10/03/2025 | 21/02/2025 |
Pharmacy inspections
Inspection reports and learning from inspections