| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | The pharmacy team access the controlled drug cabinets and dispense medicines when the responsible pharmacist isn’t at the pharmacy. The pharmacy cannot show that all its medicines it needs to keep in a refrigerator have been stored at the right temperature. |
The pharmacy team have been referred back to our Standard Operating Procedures showing the Responsible Pharmacist (RP) regulations and activities which can be conducted when an RP has signed in and when an RP has not signed in. Pharmacy team will be shown how to take and record the temperatures of the fridges to show cold-chain lines are stored correctly. |
11/12/2025 | 18/12/2025 |