| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not manage all the risks for providing its services. Written procedures available to its team members do not include core information about the responsible pharmacist's (RPs) role or the arrangements in place for the dispensing and general management of controlled drugs. This creates a risk of team members not working in accordance with regulatory requirements. |
Standard Operating Procedures (SOPs) for Lodge Moor Pharmacy will be reviewed to ensure they describe clearly and in full the role of the Responsible Pharmacist (RP) on a typical day and that staff are fully aware of what aspects of running the pharmacy they can expect the RP to be in charge of. A new SOP will be made which clearly outlines how to handle Controlled drugs with regards to receipt, dispensing and record keeping, as well as what to do when CDs are returned by patients. |
26/05/2026 | 26/05/2026 |
| 1.6 | The pharmacy does not keep some of its records in accordance with requirements. Its RP record contains inaccurate information about when a RP has been in charge of the pharmacy. And its team members do not make accurate records of the prescriber's details when entering the supply of private prescriptions into its Prescription Only Medicine register. |
A PMR flaw has been identified where the RP log entries are being made incorrectly (inadvertently) when different users have to log in again after being timed out to label prescriptions. Therefore, we will subscribe to a specific online software package which allows us to make accurate records of the responsible pharmacist in charge and any absences etc. For private prescriptions, all staff will be required to go over this SOP so they are aware of the importance and legal requirement of the correct prescriber details needing to be entered at the point of dispensing, as the entry is logged automatically once the private prescription has been labelled. |
26/05/2026 | 26/05/2026 |
| 4.3 | The pharmacy does not have effective processes to ensure all medicines are safe to supply. It holds medicines outside of the manufacturer's original packaging and without the appropriate safety information included on the temporary packaging. Its fridge is over capacity, and some medicines may be vulnerable to damage due to being in contact with the walls of the fridge. And the batch number and expiry date of medicines it assembles into multi-compartment compliance packs are not always available to pharmacists completing the final accuracy check of these packs. This means the pharmacy may supply medicines which are not suitable for people. |
We will ensure that all staff are retrained and are made aware to keep all medicines in their original packaging to protect them from degradation and if for any reason we have to take medicines out of the original packaging, then they will be clearly marked with the drug name, strength, batch number, and expiry date. For items requiring cold storage in the pharmacy fridge, we will ensure that staff are reminded of the need to keep the fridge tidy to guarantee full air circulation. Staff will also be reminded to make sure that no medicines touch any walls of the fridge when taking medicines out or putting items in. Staff involved in ordering fridge lines will be reminded of our twice a day delivery schedule so we can reduce our stock holding to prevent overcrowding. All staff involved in preparing Dosette boxes will be asked to revisit the SOP for Multi-Compartment Compliance Packs (MDS) so they are aware of the importance of leaving tabs for the batch number and expiry date of every medication placed in a compliance pack for the checking pharmacist to verify. |
26/05/2026 | 26/05/2026 |
| 4.4 | The pharmacy does not have appropriate arrangements to ensure it receives notification and acts on of all medicine recalls and patient safety alerts. There are no assurances that it is carrying out appropriate checks when concerns about the safety of a medicine are raised. |
All dispensing staff will be made aware of and trained on how to access and action medicine recalls. We will introduce a formal patient safety alert folder where all alerts are stored once completed and signed by an appropriate team member to confirm that all actions required have been concluded. Not all alerts were being received from the MHRA and we have now signed up to the Central Alerting System (CAS). Staff will carry out immediate stock checks and recalls when safety concerns arise and the RP will oversee and ensure all recalls are actioned appropriately. Our SOP will be updated to ensure that timeframes for actioning recalls are clear and the various measures to be taken for different types of recall are easy to understand and carry out. |
26/05/2026 | 26/05/2026 |
Pharmacy inspections
Inspection reports and learning from inspections