| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 2.2 | The pharmacy does not always enrol team members on the relevant training for their roles. So, they may not have the knowledge and skills they need to undertake their tasks safely and effectively. |
Relevant team members are currently being enrolled onto an accredited Dispensing Assistant course. |
28/11/2025 | 28/01/2026 |
| 4.3 | The pharmacy has not fully assessed and mitigated the risks of removing medicines from their original packs as part of the assembly of multi-compartment compliance packs. It does not have a written procedure in place for deblistering medicines. And although it takes some actions to reduce the risks of medicines degrading once they have been removed from and stored outside their original packaging, it has not considered which medicines are suitable for this process or if they should be kept in their original packs until dispensed. This could affect the efficacy of some medicines supplied to people. |
The compliance aid SOPs are being updated to ensure that all steps and procedures relating to deblistering medicines are included. All medication that is dispensed in to compliance packs will be reassessed to ensure that they are suitable to be deblistered. Supporting evidence will be gathered and retained for reference. |
28/11/2025 | 28/01/2026 |
| 5.1 | Although most medicines are suitably stored there are inadequate controls to prevent inappropriate access to some medicines that require secure storage. |
A key safe has been installed to ensure that CD keys are stored securely when not in use. |
28/11/2025 | 28/01/2026 |
Pharmacy inspections
Inspection reports and learning from inspections