| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy largely keeps the records it needs to in line with legal requirements. However, it does not frequently audit records for its higher-risk medicines which has resulted in discrepancies. This also heightens the risk of errors and possible diversion issues. |
The RP and SI to ensure a monthly audit is conducted as a minimum or shorter intervals based on use of high risk drugs to ensure discrepancies are identified if any and addressed at the earliest available opportunity. |
14/11/2025 | 13/11/2025 |
| 4.3 | The pharmacy does not always manage its stock medicines in a safe and effective way. It does not store cold chain medicines under the required conditions. And it sometimes stores medicines outside of its original packaging without making a record of the required details to identify the medicines in the event of a safety recall. So it cannot always demonstrate that its stock medicines are safe to supply. And some of its stock medicines are not stored securely to prevent unauthorised access. |
All cold chain medicines must be stored into the fridge upon receipt and temperature logs maintained. Conduct a full stock audit to ensure compliance with secure storage requirements. Implement a structured expiry date check system with regular documentation. This should be reviewed by the RP monthly to ensure compliance and a team huddle to ensure learning from near misses and errors due to expiries are implemented Re-train all pharmacy staff on stock management and proper storage procedures. Ensure controlled drugs and prescription-only medicines are securely stored at all times. Ensure balance checked are done more frequently based on frequency of dispensing of each CD. Reduce medicine stored outside of original pack but if unavoidable then ensure Batch, Expiry, Brand and appropriate information is recorded on the product box. All loose medicines must be stored in a white box with details but best practice to keep in original packaging. |
14/11/2025 | 13/11/2025 |