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Pharmacy inspections

Inspection reports and learning from inspections

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Well (1088497) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
2.1

The pharmacy's team members are deployed in such a way that, for periods of time, there are not enough team members to operate the pharmacy safely and effectively. The pharmacy team is not able to manage its workload effectively and complete routine housekeeping tasks, such as keeping the premises clean and tidy.

- Review the following to identify any time period when there are not enough colleagues to operate the pharmacy safely and effectively:
(1) Current staffing levels and compare it against MaxE.
(2) Complete or update the staffing and capability assessment and appropriately assign activities which can be carried out by the ACT.
(3) Review staffing rota for the next 6 weeks.

- Review the support provided from relief colleagues to cover unplanned absence and initiate the recruitment process if necessary.
- Engage patients to sign up SMS notification and encourage them to come to the pharmacy when they have received the SMS notification.

26/02/2025
3.3

The pharmacy's premises are not maintained appropriately and do not reflect the cleanliness expected in a healthcare setting.

Create a cleaning rota and ensure all colleagues are aware of the expectations.

AOM to check whether the cleaning rota is followed during pharmacy visits.

26/02/2025 12/03/2025
3.5

The consultation room is not kept in an appropriate condition for people to use to receive healthcare services.

Create a cleaning rota and ensure all colleagues are aware of the expectations.

AOM to check whether the cleaning rota is followed during pharmacy visits.

26/02/2025 12/03/2025
3.1

The dispensary is disorganised and cluttered. It has limited clear space to be able to dispense and check medicines safely. There are items on the dispensary floor which are tripping hazards for team members. All this is impacting the overall efficiency of the dispensing process. And it may increase the risk of dispensing mistakes or accidents.

Reorganise and declutter the dispensary

Remove any tripping hazards.

Arrange a deep clean for the pharmacy.

Organise medications in a systematic way on the Pharmashelf to prevent selection errors.

26/02/2025 12/02/2025