| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.2 | The pharmacy sell medicines and hands out prescriptions in the absence of a responsible pharmacist putting people at risk. |
Two team meetings have now been had and it has been made clear that all staff members will adhere to the rules regarding RP supervision. |
10/04/2026 | 28/03/2026 |
| 4.3 | The pharmacy does not maintain fridge temperature records and so cannot evidence that items requiring refrigeration are suitable for use. The pharmacy has loose tablets in bottles without appropriate labelling and so cannot guarantee what the products are. Some medicines are kept in an unlocked consultation room and therefore not safe from unauthorised access. |
All staff members have now been retrained on how to check max and min temps on the pharmacy fridge, how to reset the temps and how to record daily readings on the new fridge temp log on PharmaSmart. The staff have been instructed to clearly mark batch numbers and expiry dates if they have to use a non-original box or bottle. We do keep some EHC medicines in our consultation room to aid the contraceptive service, however this room is always kept locked and the key with the RP. |
10/04/2026 | 28/03/2026 |
| 5.2 | The pharmacy keeps some measuring equipment in areas unsuitable for pharmacy services putting the staff at risk. |
I have reminded staff that all measuring cylinders are kept clean, washed out and stored at the dispensary sink, certainly not left in the kitchen after cleaning. We have also clearly labelled the measuring cylinders with "METHADONE" and "WATER". |
10/04/2026 | 28/03/2026 |
| 1.1 | The pharmacy does not have updated SOPs as raised in the previous inspection. This means the team may be following outdated procedures and process. |
The SOPs have recently been transferred to an electronic version and we are no longer using the old paper copies. Since this inspection, the SOPs have been reviewed and updated further to reflect changes in Responsible Pharmacist Regulations. |
10/04/2026 | 28/03/2026 |
| 1.6 | The pharmacy does not keep adequate legal records for responsible pharmacists and special products so they cannot demonstrate who the pharmacist was on set days or how special products were supplied. |
I have instructed all pharmacists and support staff to sign in and out using the new electronic RP register and for support staff to guide any new locums who are not sure. |
10/04/2026 | 28/03/2026 |
| 1.2 | The pharmacy does not record their mistakes so miss opportunities to identify trends and learn from their mistakes. |
We have now moved over to an electronic near miss recording system which is incorporated into RxWeb our PMR provider. All staff members have now been shown how to use this effectively. |
10/04/2026 | 28/03/2026 |
| 1.3 | Staff are performing roles without adequate supervision from a pharmacist which means that people are at risk of inappropriate supplies. |
Our MCA, is still in training and overlooked the fact that P meds cannot be sold without the responsible pharmacist being on the premises. I have now made her re-look at her training pack and made her sign the updated SOPs. |
10/04/2026 | 28/03/2026 |
| 2.2 | Team members are performing duties without appropriate pharmacist supervision or qualification. |
The responsible pharmacist should be on the premises at all times, if they leave for any reason a sign should be put up stating no P meds to be sold or prescription bags handed out. |
10/04/2026 | 28/03/2026 |
Pharmacy inspections
Inspection reports and learning from inspections