| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | Pharmacy team members have not completed training records for the 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. In addition, the pharmacy's standard operating procedures do not always reflect the activities that take place in the pharmacy, which may increase the risk of errors. |
Even though members of staff have all acknowledged standard operating procedures that are currently in place, we acknowledge the essential need to ensure all pharmacy team members are aware and up to date with all the SOPs within the pharmacy. All staff members will read and sign all SOPs. Furthermore, we are actively amending all SOPs to closely reflect procedures that we already carry out but may not be accurately documented within these documents. |
08/08/2025 | |
| 1.6 | The pharmacy generally keeps the records it needs to by law. But records of higher-risk medicines are poorly maintained, which may increase the risk of errors or diversion. |
Record keeping of higher-risk drugs will be improved and a new software platform has been implemented to help with this, as there have been ongoing issues with our current record-keeping software system. |
08/08/2025 | |
| 4.2 | The pharmacy team delivers some medicines by posting them through people's letterboxes or leaving them in safe places. This practice may compromise confidentiality and increases the risk of errors. |
We have identified the risks of posting medicines through people's letterboxes and will only do so as a last resort, assessing the risks and obtaining consent for this on a case-by-case basis. Our SOP will be updated to reflect these changes. |
08/08/2025 | |
| 4.3 | The pharmacy team does not always routinely record the medicine fridge temperatures. This makes it difficult for them to know that medicines needing cold storage are stored properly and are safe and fit for purpose. |
We will be routinely recording fridge temperatures on our newly implemented software platform. |
08/08/2025 |
Pharmacy inspections
Inspection reports and learning from inspections