| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy doesn’t have written standard operating procedures for all its key processes, this includes for date checking medicine stock and for dispensing multi-compartment compliance packs. And team members do not always follow the pharmacy’s procedures or best practice, including supplying some higher risk medicines in instalments without appropriately checking the person’s identity and not maintaining running balances of such medicines. This means the pharmacy does not manage all risks with its services properly. |
SOP for CD balance checks, date checking medicines, instalment supplies, private prescriptions and dispensing multi-compartment compliance packs to be implemented. All team members to read and sign updated versions. A running balance to be maintained for all Sched 2 CDs, and regular verification checks to be carried out on these balances. |
31/12/2025 | 17/12/2025 |
| 4.2 | The pharmacist does not always confirm people’s names and addresses and double check prescriptions when handing out medicines for some higher risk medicines. And they do not always make all appropriate checks needed before dispensing some private prescriptions. So, there is a risk people may not receive the right medicine or receive medicine which is not appropriate for them. |
All medication, especially CDs, to be double checked, names and addresses are checked regularly - daily patients are recognised by all the staff, so addresses are not always confirmed, but other specific details confirmed. Private prescription SOP in place, team to read and sign. Superintendent pharmacist will review all private prescriptions on a weekly basis and maintain a record of any feedback to the pharmacy. |
31/12/2025 | 17/12/2025 |
| 4.3 | The pharmacy doesn’t store all its higher risk medicines as it should. And it does not always suitably identify the risks of unauthorised access to these medicines. |
All High risk medicines will be stored in CD cabinets. All cabinets will be appropriately secured. A full pharmacy date check has been done (please find the matrix with this plan) and going forward a regular 3 month check will be done. |
31/12/2025 | 17/12/2025 |
Pharmacy inspections
Inspection reports and learning from inspections