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Pharmacy inspections

Inspection reports and learning from inspections

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Duncans Pharmacy (1040822) - Improvement action plan

GPhC Reference 1040822

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.7

The pharmacy does not always ensure that confidential information is stored securely. This may increase the risk of sharing patient sensitive information.

We have moved the large ready scripts away from sight of patients to the dispensary and replaced them with smaller ready bags in an opaque crate where the contents are not visible. A photo has been sent of this adjustment. In addition, we are looking to sight another shelf bay in the corridor to place uncollected parcels of nutrition drinks due to their size in an effort to increase free floor space. The problem of uncollected scripts remains despite numbers of texts to the patients and after dispensing scripts in a timely manner as per our contract.

 04/07/2025 08/07/2025
2.2

The pharmacy does not always ensure that its team members are suitably trained or enrolled on training courses appropriate for their role. This may mean they do not have the right skills and knowledge for the activities they do.

Staff training has been reviewed and safeguarding level 1 and 2 are to be refreshed across all staff at the branch with pharmacists to level 3 as these have not been undertaken for over 2yrs. Level 1 training will be done at the branch with staff member in the consultation room online starting W/C 23 June to finish by first week July or sooner. Level 2 and 3 will be undertaken away from branch and expected to be completed by mid-July. This endeavour will be monitored by the SP on an ongoing basis with further training to be managed on a tablet which is being obtained from Alphega where all the SOP’s and training should eventually reside, and staff should be able to read about processes relevant to their training. We are moving most of our governance to electronic platforms as managing compliance has become more difficult as time and financial pressures have increased. We have started trialing Pharmsmart for several solutions and if all goes well then, we will commission this platform to aid compliance.
Training is carried out by the SP on a daily basis whilst our staff are dealing with issues and patients, to continually improve how they interact and counsel so that we operate safely and minimise risk-this is important for governance and the pharmacy however we are guilty of not recording these events. A diary is being set up to do this but will not replace formal training which is important when monitoring performance.
Habib (assistant) has been enrolled in the NPA Dispensary Assistant course. This course should be completed in 6-8months on average.

 04/07/2025 09/07/2025
4.3

The pharmacy cannot show that it always stores medicines which require refrigeration appropriately. And it does not always ensure that all of its prescription-only medicines are stored securely.

After speaking to the staff, we have put a recording reminder on the PMR and made it a joint responsibility for recording temperature across the 2 fridges daily. In addition, we have got data loggers to manage data which, once set up, will record on an ongoing basis as well. This protocol will be audited by the SP on a weekly basis to monitor compliance
We have also trained two more staff to empty the dehumidifiers when indicated and reset the machines so that basement humidity is lower than 60% recommended for safe storage as per MHRA-typically we aim for below 50% in a cool environment. The SP will monitor and audit this protocol.
POM’s which were in the reach of patients have been moved away as has the bin with the returned inhalers for recycling.
The second CD cabinet in the basement is for expired drugs only and is not accessible to anyone except the SP. This allows us to separate working stock, however, with the increase in prescribing and stocking of CD’s for neurodiversity our cabinet is becoming fuller than we would like. The SP has applied to NHSE to be authorised to destroy out of date CD’s and has made an application to do so for each branch which will free up the cabinet in the basement for transfer of drugs which are not often prescribed. The SP will complete this task in the next quarter.
Monitored dosage systems will be assembled, checked and sealed in a timely manner with minimum time between these tasks. MDS’s are challenging to manage due to the time and safety issues pertaining to their dispensing. We have been refusing to take on new patients because of the extra workload and pressure to manage this process whilst we improve our processes. We have had 2 members of staff return from maternity break in the last 2 months and have two leaving in the next 4 weeks so workload will not improve in the summer months and therefore we may need to employ locum personnel who usually have a limited skillset.

 04/07/2025 09/07/2025
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