| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have documented written procedures for all of the services it provides, including some higher-risk services, such as delivery of medicines to people which require temperature control. And team members do not always follow the written procedures that are available which increases risk. |
New SOP’s will be written to cover all services being offered by the pharmacy. Staff will also read through all SOP’s again and we will have a team meeting to discuss to ensure there is compliance going forward. |
11/07/2025 | 28/07/2025 |
| 1.2 | The pharmacy does not proactively audit or review the private dispensing services it provides. This includes completing clinical audits of supplies and monitoring prescribers to show they are eligible and safe to prescribe. The pharmacy does not have adequate systems in place to identify prescribing trends and prompt effective interventions. So, the pharmacy is unable to show how it continually monitors and improves the safety and quality its services. |
We will complete a 3 monthly audit of the private prescriptions we have issued in conjunction with the new risk assessment which is being carried out. The risk assessment will then be repeated and updated as appropriate. |
11/07/2025 | 28/07/2025 |
| 1.6 | The pharmacy records the details of the private prescriptions it supplies. But it does not always capture accurate information about the prescriber such as their registered name or their correct address. This means that the pharmacy does not have the correct records required by law. The pharmacy does not always maintain an audit trail of who it supplies unlicensed medicines to, which may mean that it is unable to respond effectively in response to concerns about the medicines supplied. |
All staff have been reminded of the importance of ensuring accurate records are kept and we have gone over the relevant SOP’s again in a team meeting to ensure everyone understands this. |
11/07/2025 | 28/07/2025 |
| 1.1 | The pharmacy does not identify and manage all the risks for the services it provides at a distance. It does not have detailed risk assessments for private prescriptions it delivers to people for botulinum toxins and weight loss medicines. And it cannot show it has considered the need to restrict the quantity and frequency of the medicines it supplies or how it verifies that botulinum toxins are only prescribed following a face-to-face consultation with a person. |
Risk assessments will be carried out for all services which the pharmacy offers. These will then be repeated once measures have been taken to mitigate the risks identified in order to show the steps taken have been effective. We will also put limits in place for the quantity that may be supplied for weight loss medications and botulinum toxins and ensure that the frequency of any repeat prescriptions are appropriate as per our SOP’s. We will also now ask prescribers to confirm that a face to face consultation has taken place for prescriptions for weight loss medications and botulinum toxins and ask them to provide the date for when this consultation occurred. |
11/07/2025 | 28/07/2025 |
| 3.1 | The pharmacy’s website does not display all required information including about the superintendent pharmacist and the pharmacy’s registration number. This is not in line with requirements and makes it harder for people to check the pharmacy’s registration details. |
The error on the website which was causing this issue has now been corrected and the required information is now being displayed. |
11/07/2025 | 28/07/2025 |
| 4.2 | The pharmacy does not have robust systems to ensure it always makes the necessary checks when dispensing medicines to ensure they are appropriate for people to use. For botulinum toxins the team do not verify that prescribers have completed face-to-face consultations, and they do not always ensure administration instructions are included on the label. The pharmacy doesn’t obtain additional information for medicines used for unlicensed indications and it does not query when large quantities of medicines are prescribed. This makes it difficult to ensure the medicine is appropriate for people. |
As per our SOP’s the prescriber will always be verified via their professional body to confirm they have prescribing rights. We will now ask prescribers to confirm that a face to face consultation has taken place and ask them to provide the date for when this consultation occurred. We will now also request administration instructions are added for any weight loss or aesthetics prescriptions that we receive that do not initially have them included. We will also stop supplying medicines for unlicensed indications such as Ozempic for weight loss purposes. If large quantites of a medicine are requested the prescriber will be contacted and asked to provide written confirmation of the reasons for this request. |
11/07/2025 | 28/07/2025 |
| 4.2 | Not all team members, including the responsible pharmacist, have access to the pharmacy’s online platforms used for receiving private prescriptions and for selling pharmacy-only medicines through its website. So they cannot demonstrate how they maintain records and access the necessary information to make a decision on the suitability of people's treatment. |
Team members now have access to all the online platforms |
11/07/2025 | 28/07/2025 |
| 4.2 | The pharmacy regularly delivers medicines which require cold storage. But it has not made the necessary checks to ensure the packaging it uses to deliver these medicines appropriately maintains these medicines at the correct temperature. So, it cannot be sure these medicines are suitable for use. |
Validation studies are being carried out using a calibrated data logger. |
11/07/2025 | 28/07/2025 |
Pharmacy inspections
Inspection reports and learning from inspections