| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has written standard operating procedures. But some of the procedures have not been reviewed since 2016 and do not cover key risks such as operating in the absence of a responsible pharmacist. So the pharmacy team may not fully understand what is expected of them. |
New SOPs have been downloaded and will be read and signed by members of the team. |
20/10/2025 | 08/10/2025 |
| 1.2 | The pharmacy team discuss when mistakes occur to help learn from them. But the pharmacy team do not routinely record the mistakes so they can review them and look for underlying trends. An example of an error which was reported by the superintendent pharmacist had not been recorded and investigated. So the pharmacy is unable to demonstrate how it learns from errors, and show what action is taken to reduce the risk of similar mistakes happening again. |
New SOP is in place for the team to follow. |
20/10/2025 | 08/10/2025 |
| 4.2 | The pharmacy has a substance misuse service which is provided by the responsible pharmacist on duty. But it does not have sufficient systems in place to ensure the risks associated with service have been addressed. Such as using multiple team members to check each other’s work, having robust processes to assemble medicines, and supplying them to patients safely. There have also been examples of incidents related to this service. In the absence of having sufficient systems in place the pharmacy is unable to demonstrate this service is safe and effective. |
Methadone to be checked by another member of staff and signed on dispersed label as well as pharmacist initials on label. |
20/10/2025 | 08/10/2025 |
| 4.3 | The pharmacy does not have sufficient processes to monitor all of its stock medicines are stored safely. Some fridge medicines are stored without temperature records to ensure medicines that require cold conditions are always stored within their required temperature range. And liquid medicines do not always have the date of opening written on. So the pharmacy is unable to show medicines are always fit for purpose. |
All stock date checked quarterly as well as having expiry date on item so dispensers can see when item to be removed off stock . |
20/10/2025 | 08/10/2025 |
Pharmacy inspections
Inspection reports and learning from inspections