| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have standard operating procedures (SOPs) for all the services it provides. This includes procedures relating to the responsible pharmacist, NHS Pharmacy First and NHS Pharmacy First Plus. And not all team members have signed the SOPs that are available to show they have read and understood them. So, they may not have all the required knowledge to complete their roles safely and effectively. |
To meet this standard, the superintendent will create the required SOPs, deliver staff training, and obtain staff signatures to confirm acknowledgement of all SOPs to date. |
17/10/2025 | 29/10/2025 |
| 1.2 | The pharmacy does not routinely record mistakes that are identified during the dispensing process, known as near misses. And there is no process to regularly review these mistakes. So team members may miss opportunities to identify patterns, learn from their mistakes and improve the safety of the pharmacy's services. |
To meet this standard, the superintendent has created an electronic near miss log to improve accessibility for staff, enabling them to record incidents and allowing for regular reviews. |
17/10/2025 | 29/10/2025 |
| 4.3 | The pharmacy does not always store its medicines appropriately, including ensuring that medicines removed from the manufacturers packs are labelled with the required information. So, it could be harder for the pharmacy to respond effectively to a query or safety recall. The pharmacy does not always ensure that checks are completed to confirm medicines requiring refrigeration are kept within the required temperatures. And it cannot show that checks of expiry dates of medicines are completed regularly. This increases the risk of people receiving medicines that are unsuitable for them. |
To meet this standard, the superintendent will ensure medicines are stored appropriately at all times. Medicines removed from manufacturers’ packs will be labelled with the required information. Staff will receive training to reinforce their responsibilities for appropriate storage conditions. Checks will be carried out to confirm that refrigeration temperatures remain within range, and expiry date checks will be completed to ensure medicines supplied are suitable for use. |
17/10/2025 | 29/10/2025 |