| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | Some pharmacy team members have not read the most recent versions of standard operating procedures that underpin the services they provide. So they may not be able to demonstrate that they fully understand their role or responsibilities. And there is a risk that they may not be able to provide pharmacy services safely and effectively. |
All team members will read and sign the most recent versions of the SOPs. |
10/06/2025 | 23/05/2025 |
| 1.6 | The pharmacy generally keeps the records it needs to by law. But records of higher-risk medicines are not well-maintained, the responsible pharmacist record does not always show the time at which the pharmacist relinquished responsibility for the safe and effective running of the pharmacy, and records of unlicensed medicines do not include patient details, so team members may not always be able to show exactly what has happened if any problems arise. |
All controlled drug registers to be checked and a balance check to be made, with any registers that have errors corrected and reported. All discrepancies will be reported to the appropriate CDAO and weekly checks of the registers will be carried out going forward by a dispenser and will be checked by the responsible pharmacist. Pharmacists will ensure they sign both in/out of the Responsible Pharmacist register and this will be monitored by all regular pharmacy staff. A new process will be introduced for unlicensed medications by which patient details will be attached to invoices/certificates that will be retained in the pharmacy for an auditable trail. |
10/06/2025 | 23/05/2025 |
Pharmacy inspections
Inspection reports and learning from inspections