| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 3.4 | The pharmacy forms part of a shared premises with a general village store and Post Office which have different opening and closing times. However, the pharmacy has not taken appropriate steps to help prevent unauthorised access when closed. |
Following the inspection, we have taken steps to address the separation and security of the pharmacy premises. We are currently in contact with a builder to arrange the necessary works to physically enclose the pharmacy area. In the interim, we have implemented clear controls to ensure that when the shop is open on Saturdays, no pharmacy-related activities are undertaken. Staff are not permitted to sell or supply any P medicines or undertake any other pharmacy-related transactions or activities when the pharmacy is closed. |
26/10/2026 | |
| 3.2 | The pharmacy provides various clinical services as part of its NHS contract. But the premises does not have a purpose-built consultation room and is reliant upon a curtained area of a general village store. This does not provide the necessary structure to protect people’s privacy and dignity for the provision of such pharmacy and clinical services. |
Following the inspection, we have utilised one of our store rooms to create a dedicated consultation room. All materials previously stored in the room have been removed, and the room has been fully refurbished and redecorated for this purpose. The room is now designated as a private consultation area, providing an appropriate level of privacy and confidentiality for patients requiring consultations. |
26/10/2026 | |
| 1.1 | The pharmacy has written procedures for the services provided. But part of the premises forms part of a village store, which is open at times when the pharmacy is closed. Non-pharmacy team members have access to all parts of the building and have not undertaken training on the written procedures to help manage risk. So they may not understand the limitations to their role. |
We have reviewed the roles and responsibilities of all non-pharmacy members of staff to ensure that their duties are appropriate to their level of training and do not extend into pharmacy-related activities. Non-pharmacy staff have been asked to familiarise themselves with the relevant SOPs applicable to their roles. Their duties are primarily limited to Post Office services, with one member of staff assigned solely to administrative duties. For the member of staff undertaking administrative duties, we have clearly restricted their role to administrative responsibilities and ensured that they are not involved in any pharmacy-related activities. All other counter staff have completed the required training relevant to their roles and have received certification upon completion. We will continue to ensure that staff remain appropriately trained and that their responsibilities remain within the scope of their training and role. |
26/10/2026 | |
| 1.6 | The pharmacy has records related to the pharmacy services provided. But it does not state when the responsible pharmacist has ended their responsibility. And it does not record the details of the prescriber when supplying private prescriptions. Records for higher-risk medicines are not kept up to date. So the pharmacy may not have the necessary, or up to date, information available in the event of a query or a concern. |
Following the inspection, we have implemented a formal process to accurately record the Responsible Pharmacist’s sign-in and sign-out times. The required records are now being maintained accordingly, and supporting evidence has been attached for review. In relation to private prescriptions, we have implemented a process of recording the prescriber’s details on POM Smart when processing these prescriptions. We have also reviewed the recording and monitoring of high-risk medicines and have ensured that the required alert cards are now in place. This supports appropriate identification and monitoring of high-risk medicines, and we are ensuring that the associated records are kept accurate and up to date. |
26/10/2026 |
Pharmacy inspections
Inspection reports and learning from inspections