| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | The pharmacy does not record the temperature of the pharmacy fridges. So, it cannot show that their temperatures remain within the appropriate limits. So, there is a risk that medicines that require refrigeration are not stored appropriately and are not fit for use. |
Similar to the aforementioned (1.2), we have decided to upgrade our PharmSmart package to include ReportSmart (This also includes the facility for fridge temperature monitoring). Alongside (1.2) (also on ReportSmart), we decided that this would keep everything together (rather than separate word documents/paper trails. We have made two separate fridge logs (for our main use fridge and our back fridge). Daily logs have (since our inspection) been recorded and will continue to be done so going forward. |
24/07/2026 | |
| 1.2 | Team members do not keep records of the mistakes they make when dispensing. And they do not carry out regular reviews to spot patterns or trends. So, they may be missing opportunities to learn when things go wrong and take action to prevent them happening again. |
We have upgraded our ‘PharmSmart’ hub to include Near Miss/Error Reporting under ‘ReportSmart’ (this is to keep as much paperwork as possible together under one hub). Because numerous staff members are not full time, our pharmacist will write the near miss(s) in the near miss log (including the checking pharmacist name and the dispensers name) in the first instance. Staff will also be shown how to write up near misses (SOP getting written asap since new procedure) and we will then be conducting monthly reviews into error patterns and how best to prevent them going forward. |
24/07/2026 | |
| 1.6 | The pharmacy does not keep appropriate records of controlled drugs people return to the pharmacy for destruction. So, the pharmacy can’t show who the medicines were received from or when they are destroyed in line with legal requirements. |
Our SOP is currently under review with a few changes already to be added; a patient (or representative) form is to be created. This will identify the controlled drugs being returned; who the patient was and naming the patient/representative who brought them in for destruction. The patient/representative will also sign the form, and data will then be transferred to PharmSmart for recording and then destruction. |
24/07/2026 |
Pharmacy inspections
Inspection reports and learning from inspections