| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has written procedures in place to support safe working but there is evidence that these aren't always followed in practice. For example, dispensing mistakes are not recorded, reported and reviewed in line with the procedures. And team members do not initial dispensing labels, making it harder to investigate incidents or identify any specific learning needs. |
Each team member will correct their near misses and record them on the near miss log. The near miss log will be reviewed by the pharmacist monthly. When dispensing. The dispenser will initial the prescription when picking stock, and the finished item will show the initials of the dispenser and the checker on the dispensing label. |
26/01/2026 | 12/01/2026 |
| 1.2 | Dispensing errors are not always recorded and reported. And the pharmacy cannot show that it properly reviews these events to identify improvements and to minimise the chance of similar events happening again. |
Dispensing errors will be reported and recorded on the NHS Learn from safety events log in, created for the pharmacy. |
26/01/2026 | 12/01/2026 |
| 2.2 | A team member who has been employed at the pharmacy for well over three months has not completed and is not currently enrolled on the required training for the role they undertake. |
All team members who have not completed the appropriate training will be enrolled on Buttercups Healthcare assistant course. |
26/01/2026 | 12/01/2026 |
| 4.3 | The pharmacy cannot demonstrate that medicines requiring refrigeration are always stored at the right temperatures. |
Fridge temperatures will be checked and recorded daily. |
26/01/2026 | 12/01/2026 |
Pharmacy inspections
Inspection reports and learning from inspections