| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not make records of mistakes it makes. And so it cannot show that it has learnt from these or taken any actions to prevent similar mistakes happening again. |
Near miss error logs will be put in place. A monthly meeting will be held with the team to discuss the near miss logs and a weekly template will be sent across for review. SOPs to be reviewed by team members regarding near miss recording. |
13/03/2026 | 05/03/2026 |
| 4.2 | The pharmacy does not have signed patient group directions (PGDs) available to refer to when providing services requiring these. This means the pharmacy cannot show it is providing these services safely or lawfully. |
Relevant PGDs for the services being provided to be available in the pharmacy. Before starting any new service, the team are briefed and those involved in providing the service all sign the relevant PGDs prior to starting it. |
13/03/2026 | 05/03/2026 |
| 4.3 | The pharmacy does not store all medicines requiring safe custody as required. And it cannot show that medicines requiring cold-storage are always stored at the required temperatures which means that medicines may be supplied which are no longer suitable for use. |
All medicines requiring safe custody to be secured securely and those requiring cold-storage will be moved to the main fridge where the temperature can be monitored until a new fridge is available. |
13/03/2026 | 05/03/2026 |
Pharmacy inspections
Inspection reports and learning from inspections