Madesil Pharmacie (1041298) - Improvement action plan

The pharmacy does not routinely record audits of controlled drug running balances and it doesn't promptly record receipt of controlled drugs which are returned to the pharmacy for safe disposal. This may make it harder to resolve any discrepancies or show how it accounts for these medicines.

• All CD’s have been audited with
balance checked and verified by
pharmacist and dispenser. Stamped with date 12/5/2025 .
• This process to be repeated for all
CD’s every 1-2 weeks depending on
usage
• All CDs 2 and 3 which are patient
returns have been recorded in NPA
CD destruction register and
denatured safely.
• Staff briefed to record future patient
returns on same day upon receiving

The pharmacy does not manage unwanted medicines and controlled drugs (CDs) effectively. It has accumulated a large amount of expired CDs which require an authorised destruction. And it does not always separate CDs which are not stored in the cabinet for denaturing before disposal. In addition, other obsolete medicines are not always stored appropriately.

All obsolete/expired CDs have been
reported to NHS England on
CDreporting.co.uk
• Awaiting response from CDAO to
authorise a witness for disposal
• Future CD class 3 expired stock and
patient returns to be kept separate in
the CD cabinet – clearly marked and
denatured periodically in presence of
staff /witnesses
• All other obsolete meds to be stored
in yellow SRCL containers which will
be sealed and only then stored at the
back in basement for collection
• Partially full / unsealed SRCL boxes to be kept behind a locked cabinet
which has been newly ordered. NO
access to staff/public except
pharmacist to this cabinet