| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 5.1 | The pharmacy offers a vaccination service without an appropriate anaphylaxis kit readily available. So, this could lead to delays is people receiving treatment for an anaphylactic reaction. |
Confirm anaphylaxis pack present and ensure they are available and accessible in appropriate locations. Brief the team on the location and the need to inform locum and relief pharmacists. Check expiry regularly and replace as needed. |
06/07/2026 | 03/07/2026 |
| 2.1 | The pharmacy does not have enough staff to operate safely and effectively for the duration of its activities. During the inspection, there was an almost constant queue of people waiting to be seen which caused long waiting times in people getting seen in the pharmacy. And this caused the team to fall behind on dispensing and checking of medicines. The lack of staff also affected the team ability to carry out activities in the pharmacy such as regularly date checking the stock. The pharmacy does not have a regular pharmacist or manager and is relying on locum pharmacists to operate. |
Complete a staffing and capability review to confirm alignment with our internal staffing model and review training needs. Plan staff rotas for the next 6 weeks. Review any agreed Annual Leave or other planned absence and ensure appropriate cover is arranged. Review current workload and provide sufficient support to clear any backlog of labelling and dispensing. Review adherence to Best in Class processes including full use of off site dispensing hub to enable team to work within capacity. Review date checking, fridge temperature records, CD balance checks and other routine tasks. Provide support to address any areas of poor compliance with company processes. Full time Pharmacist Manager starts next week. Support team will consist of 2 x qualified pharmacy assistants and 1 x trainee pharmacist assistant. Manager will be briefed on correct process for planning annual leave. |
20/07/2026 | 21/07/2026 |
| 4.4 | The pharmacy receives safety alerts and recalls of medicines and medical devices, but it cannot demonstrate that it is able to appropriately action these safety alerts. During the inspection, the team members could not provide evidence to show that alerts were being actioned, and they were not fully sure of the process to action safety alerts and recalls. So, there is a risk that people may receive a medicine or medical device that is not fit for purpose. |
Team briefing to discuss correct process. Team to re-read and sign off SOP 19 appendix 1 to ensure they understand the correct process for Patient Safety Alerts. AOM to ensure completion. Review of compliance with previous 2026 Patient Safety Alerts to confirm appropriate actions taken. |
06/07/2026 | 03/07/2026 |
Pharmacy inspections
Inspection reports and learning from inspections