| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not identify and manage all of the risks involved with its services. Members of the pharmacy team do not have a clear understanding of the pharmacy’s operating procedures. So, they may not always work safely or fully understand their responsibilities. |
Refresh all understanding of SOPs, working practices with all staff including introducing quarterly staff appraisals |
12/03/2025 | 19/03/2025 |
| 1.2 | The pharmacy cannot demonstrate that records are made when things go wrong and there is no evidence of learning. This could make it harder for the team to review mistakes and identify any patterns or trends, so there is a risk that errors might be repeated. |
Introduce Near Miss log and weekly huddles and briefings with ALL colleagues. Incorporate LASA protocols into the |
26/02/2025 | 19/03/2025 |
| 1.3 | The pharmacy team members do not have clearly defined roles and responsibilities, appropriate to their level of training and experience. They are not always clear what activities are allowed in the presence and absence of a responsible pharmacist (RP). |
Review RP SOPs and reinstate staff roles as per next appraisal. A performance review will be undertaken to show strengths and limitations of each colleague which will govern their role and |
26/02/2025 | 19/03/2025 |
| 1.6 | The pharmacy's records are not adequately maintained. Checks of controlled drug (CD) registers found some inconsistencies. Running balances of CDs are not regularly audited so missing entries might not be identified promptly. Adjustments to methadone solution balances are made without any assessment of whether the adjustment is within a reasonable range or should be investigated and reported to the CD accountable officer, and patient returned CDs are not always recorded when returned to the pharmacy. The RP has not recorded the time they ceased their duties on many of the entries in the RP log. And the incorrect prescriber has often been recorded on private prescriptions records. |
A training session has already been undertaken on Fri 7th Feb with a trainee dispenser and the SI to activate eCDRs with our PMR system provider. An alarm will be generated at the end of the shift as a reminder for the RP to sign out. All private scripts will be now recorded |
26/02/2025 | 19/03/2025 |
| 1.7 | Team members do not use individual NHS smartcards appropriately to access people’s healthcare information. This means the information is being accessed without appropriate controls and audit trails. |
one of the trainee dispensers has undergone a training session and has been authorised to be a sponsor going |
12/03/2025 | 19/03/2025 |
| 2.2 | Members of the pharmacy team have not received any formal training. This does not meet GPhC minimum training requirements and means the pharmacy is unable to demonstrate that staff have the necessary skills to carry out their roles safely and effectively. |
All colleagues have been enrolled onto the Buttercups NVQ Level 2 in Pharmacy Services. They will be having quarterly progress reviews on the training programme over the 18 months of the course |
26/02/2025 | 19/03/2025 |
| 4.2 | The pharmacy’s compliance aid pack service is not adequately managed. Some packs are assembled in advance of the prescription and there isn’t a robust audit trail of changes to medication and communications with GPs. The packs are not adequately labelled with cautionary and advisory labels, and packaging leaflets are not included to ensure people have all of the information they need to take their medicines safely. Medicines used for the supervised consumption service are not always correctly labelled or supplied in clean containers. |
The pharmacy will review the SOP and make local amendments to introduce eRDs for the compliance aid dispensing. The RP will do further checks against all labelled script and make changes accordingly. The prescriber will initiate the eRD and is already in progress in Buxton, all comms will be via NHS mail. PILs will be added to the first instalment The RP will only use clean bottles at all times and the importance of cleanliness and hygiene |
26/02/2025 | 19/03/2025 |
| 4.3 | The pharmacy does not store and manage all of its medicines appropriately. Some medicines are not stored in their original packaging or in containers with appropriate labelling. The pharmacy cannot demonstrate that the temperature of the medical fridge is appropriately monitored or that it has a robust date checking procedure. And opened liquids with limited stability are not always dated. This means the pharmacy cannot always provide assurance that medicines are in a suitable condition to supply. The pharmacy does not suitably safeguard higher risk medicines requiring safe custody which is a security risk. |
RP will be trained on creating Freeformat labels stating BN no, Expiry, Drug name, form, For liquids additional information will state when the bottle was opened. PMR system provider will be updated to force and check Fridge temps on all workstations so mandatory entries are inserted daily. Staff appraisal and training will include CD keys will be the sole responsibility of the RP and will be sealed and signed every night by the RP. Colleagues will only brief the RP on the |
26/02/2025 | 19/03/2025 |
Pharmacy inspections
Inspection reports and learning from inspections