| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has some written procedures to support team members in their roles. But team members have not signed to show they have read and understood them. And there is no record of review by the current Superintendent Pharmacist. The pharmacy does not identify and manage all the risks for the private services it provides. For example, there are no documented risk assessments or procedures for working with third-party prescribing services to ensure the prescriptions they receive are appropriate and safe to supply to people. |
Standard operating procedures (SOPs) to be reviewed by superintendent pharmacist and signed by team members. Risk assessments and procedures to be updated and completed. This must include documentation for working with the ADHD clinic along with dispensing and delivery of prescriptions |
17/11/2025 | 28/11/2025 |
| 1.2 | The pharmacy does not audit or review the private dispensing services it provides. It cannot show that its policies and procedures are effective at keeping services safe. It holds some records of interventions on the timeliness of supplies. But there are no ongoing checks to ensure prescribers continue to be eligible to prescribe. And there are no scheduled audits to identify prescribing trends, or check that prescribing decisions follow national guidelines. So, the pharmacy is unable to show how it continually monitors and improves the safety and quality of its services. |
Documentation to highlight auditing process for private dispensing service. |
17/11/2025 | 28/11/2025 |
| 1.2 | Team members do not consistently record or review mistakes identified during the dispensing process. So, team members may miss opportunities to learn from things that go wrong. |
Near miss logs to be discussed with team members, processes to be reviewed and discussed as a team. |
17/11/2025 | 28/11/2025 |
| 4.2 | The pharmacy cannot demonstrate it always provides services safely. It doesn't always have all the information required for the pharmacist to adequately complete the clinical check on prescriptions received from the private third-party prescribing service. Team members working in the pharmacy do not have access to delivery records to check medication is successfully delivered. And there are no verification checks at the point of delivery to ensure it is received by the correct person. The pharmacy has delivered some medicines that required cold storage previously, but it did not perform testing on the packaging to ensure it maintained the appropriate temperature and that medicines remained safe to use. |
Procedures and associated guidance will be detailed to highlight:
|
17/11/2025 | 28/11/2025 |
| 4.3 | The pharmacy maintained records of fridge temperatures. But records showed the fridge was operating out with the recommended limits of between 2 and 8 degrees Celsius. So, it cannot be sure medicines requiring refrigeration are safe to use. |
Current temperatures continue to be monitored whilst waiting on new fridge arriving. |
17/11/2025 | 28/11/2025 |
Pharmacy inspections
Inspection reports and learning from inspections