| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not identify and manage all the risks for the pharmacy services it provides. It does not keep its written procedures up to date. And training records do not show that all team members have read and understood these procedures. |
SOPs to be updated to cover any recent changes to required procedures, and any new services provided. All staff will sign the SOPs to show that the SOPs have been read and understood. |
09/03/2026 | 13/03/2026 |
| 1.2 | The pharmacy does not monitor the risk of providing all of its services appropriately. Its team members do not make records of the mistakes they make during the dispensing process. And there is no evidence of reflection or learning following these near misses and dispensing incidents to help reduce risk. This means there is an increased chance of repeated mistakes occurring. |
Reinstatement of written near miss logs to replace the verbal “ know and show” procedure in place recently and prior to inspection. |
09/03/2026 | 13/03/2026 |
| 4.3 | The pharmacy does not have appropriate equipment available to support it in safely disposing of its sharps waste and patient-returned higher risk medicines. And it does not store patient-returned higher risk medicines securely as required. This increases the risk of an adverse incident occurring. |
Limited storage for high risk medicines requires their destruction in a more timely manner, rather than Ad Hoc. Monthly reviews with respect to storage and destruction will be put in place going forward to mitigate storage issues. |
09/03/2026 | 13/03/2026 |
| 4.3 | The pharmacy does not demonstrate how it monitors the suitability of the environment for storing some medicines requiring cold storage as monitoring records for one of its fridges is not available. Stock medicines are not always held in the manufacturer's original packaging. And monitoring records for the checks made to ensure medicines remain safe to supply to people are not always completed, this increases the risk of mistake occurring. |
A temporary winter fridge record, recorded on loose A4 paper, will now be added as a second fridge to PMR since the winter fridge is likely to be in use all year round going forward. Our date checking matrix will be physically filled in, rather than relying on Ad Hoc shelf and in dispensing checks. |
09/03/2026 | 13/03/2026 |
Pharmacy inspections
Inspection reports and learning from inspections