| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | Some controlled drugs are not stored in accordance with safe custody requirements. |
The pharmacy team has been reminded that controlled drugs must be secured in accordance with safe custody regulations at all times. Appropriate arrangements have been introduced to ensure that controlled drug storage requirements are consistently followed. |
26/10/2026 | 16/09/2026 |
| 1.3 | There are occasions when pharmacy team members prepare prescription medicines for supply without a Responsible Pharmacist (RP) in place, contrary to RP Regulations. |
Pharmacy team members are completing the training regarding the duties and restrictions applicable when a Responsible Pharmacist (RP) is absent from the pharmacy or when no RP has taken responsibility for the pharmacy. The training covers the legal and operational requirements for RP arrangements, the tasks that pharmacy team members may and may not undertake during an RP's absence, the procedure for reporting an unexpected absence, the arrangements for contacting the Area Manager and obtaining appropriate pharmacist cover, and the necessary record-keeping requirements. The pharmacy team is being reminded that they must follow the pharmacy's written procedures and must not assume that normal pharmacy operations can continue when there is no RP. The relevant procedures will be communicated to all team members including locum pharmacists, and their understanding will be documented through training records and competency assessments. The written procedures are available at the pharmacy and that team members know where to access them. Pharmacists have been instructed and are required to attend the pharmacy on time and in accordance with their agreed working hours. Where a pharmacist is unexpectedly delayed or unable to attend due to an emergency, appropriate locum cover arrangements have been put in place to ensure there is no gap in pharmacist cover. |
26/10/2026 | 12/10/2026 |
| 1.6 | The pharmacy does not document its methadone running balance. As a result, it may overlook or delay identifying discrepancies. |
The pharmacy has started documenting and maintaining the methadone running balance. The methadone running balance is being checked and recorded appropriately to ensure that discrepancies can be identified and investigated promptly. |
26/10/2026 | 16/09/2026 |
| 2.2 | The pharmacy employs untrained staff who have not been enrolled on a necessary training course. This means they may have gaps in their knowledge and skills which could affect the pharmacy’s ability to provide services safely. |
Any pharmacy team members identified as requiring necessary training have been enrolled on the appropriate training course. The pharmacy is ensuring that pharmacy team members have the necessary knowledge and competence for the duties they undertake. |
26/10/2026 | 16/09/2026 |
Pharmacy inspections
Inspection reports and learning from inspections