| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy does not always maintain complete and accurate records. It has not correctly recorded or investigated several inaccurate stock balances for its higher risk medicines in a timely manner. And for private prescription supply records, it regularly does not record full or correct details of the prescriber. The responsible pharmacist record has many missing entries of when the pharmacist duties ceased at the end of the working day. This makes it more difficult for the pharmacy team to resolve queries and identify errors. |
Superintendent Pharmacist (SI) has spoken to the pharmacy and reminded them of the importance of weekly controlled drug (CD) balance checks, and asked that they resume prioritising the CD count as a weekly task. The pharmacy has been given double cover 27/11/25 so that the pharmacy manager can spend the day doing a CD count and investigating any discrepancies. Once this has been done if any discrepancies still exist, we will notify the CD governance team. SI has explained to staff that our data entry forms the basis of the legal entry in the private prescription register therefore should be correct and accurate to the information on the actual prescription. SI has asked them to re-read the standard operating procedures so they fully understand how to deal with a private prescription. All staff now know to add the full and correct prescriber details when labelling a private prescription. The computer settings have been changed to force a responsible pharmacist (RP) sign on at the start of the day. No work will be able to be done on the pharmacy software until an entry has been made on the RP register. An alarm has been set to remind the RP to sign off last thing at night. |
15/12/2025 | 04/12/2025 |
| 4.4 | The pharmacy does not have a robust process for actioning Medicines Healthcare and Products Regulatory Agency (MHRA) patient safety alerts and medicines recalls. It has gaps in its records for several months. So, the pharmacy cannot be sure it receives and actions all recalls to ensure medicines are safe to use and fit to supply. |
The pharmacy have brought the drug alerts folder back into the dispensary, so it is easy to access and therefore use. The pharmacy have signed up to MHRA alerts and a discussion was had with all staff re the importance of this. Staff have been asked to search the emails for any missing alerts from the past and check that they don't have the stock. |
15/12/2025 | 04/12/2025 |
Pharmacy inspections
Inspection reports and learning from inspections