| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not suitably identify and manage the risks associated with its services. It cannot demonstrate that its team members always follow the written procedures available. So, they do not always work effectively and there is evidence that things have gone wrong which increases the risk of patient safety. |
All staff members will go through SOPs again and sign them to ensure they understand them. A log of incidents where SOPs have not been followed will be created for learning to prevent future incidents. |
01/08/2025 | 23/07/2025 |
| 1.2 | The pharmacy team does not routinely assess the safety and quality of services provided. Team members do not record the details of patient safety incidents, so they cannot demonstrate that they effectively review or learn when things go wrong. This means they miss opportunities to implement changes and make improvements. |
We will create a near miss log and incident log. The staff will record their near misses and incidents in these logs and we will review and update team practices to learn and prevent future adverse instances. |
01/08/2025 | 23/07/2025 |
| 1.6 | Pharmacy records for assuring the safety of services, including the responsible pharmacist and fridge temperature records are incomplete or unclear. And there is no record of private prescriptions previously supplied via a third-party online prescribing service. So, the pharmacy cannot demonstrate what supplies were made and to whom. |
We will maintain a clear responsible pharmacist log and temperature monitoring log for minimum and maximum fridge temperatures. Additionally, any private prescription supplies will be recorded in the private prescription log. |
01/08/2025 | 23/07/2025 |
| 1.7 | The pharmacy cannot demonstrate that its team members understand the principles of how patient identifiable information should be handled. There is evidence that confidential waste is not being adequately separated and securely destroyed which could lead to a breach of patient confidentiality. |
We will install a paper shredder to shred confidential waste, we will also train the staff using the NHS DSP toolkit. |
01/08/2025 | 23/07/2025 |
| 4.2 | The pharmacy does not effectively manage its services to make sure that they are provided safely. Services, including dispensing and the supply of compliance aid packs are not delivered in line with the pharmacy's procedures which increases the risk of things going wrong and patient harm. |
We will review the procedures again to find the reason for not following the pharmacy's procedures. We will identify areas for learning and retrain the staff to follow the procedures. |
01/08/2025 | 28/07/2025 |
| 4.3 | The pharmacy cannot demonstrate that its medicines are suitably stored and fit for purpose. Medicines are not always stored within their original container and some higher risk pharmacy restricted medicines, are not always properly secured. The pharmacy also cannot show that medicines requiring refrigeration are stored in appropriate conditions. And team members do not always follow the correct procedures when managing patient returned medicines, which increases the risk of them being inappropriately supplied to patients. |
We will train staff to identify high risk medicines and store them safely. temperature monitoring and logging will ensure that medicines that require refrigeration are stored in appropriate conditions. Any returned medicines will be disposed of right away to minimise the risk of re-dispensing. |
01/08/2025 | 23/07/2025 |
Pharmacy inspections
Inspection reports and learning from inspections