| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | The pharmacy cannot demonstrate that it has appropriate procedures for removal of expired medicines or medicines that are unfit for use. During the inspection an expired medicine, loose blisters of medicines and bottles of medicines missing important information such as batch numbers and expiry dates were found on the shelves. |
A new date checking system has been implemented and staff have been delegated sections of the dispensary/shop to date check on a monthly basis. All stock that is split and put into white boxes needs to be marked appropriately with expiry date and batch number. |
02/10/2026 | 13/10/2026 |
| 4.4 | The pharmacy receives safety alerts and recalls of medicines and medical devices, but it cannot demonstrate that it is able to appropriately action these safety alerts. During the inspection, the team members could not provide evidence to show that alerts were being actioned, and they were not fully sure of the process to action safety alerts and recalls. So, there is a risk that people may receive a medicine or medical device that is not fit for purpose. |
Safety alerts are printed off and actioned immediately. All staff are informed of appropriate action needed. Alerts are stored in the safety alerts folder. |
02/10/2026 | 01/10/2026 |
| 2.2 | Some pharmacy team members have not completed the appropriate training for their roles with an accredited training provider. So, team members may not have the required knowledge and skills to work safely and efficiently in the pharmacy. |
Team members to be immediately put on appropriate training courses for their roles to with accredited training providers so as to attain appropriate knowledge and skills for their roles. |
02/10/2026 | 01/10/2026 |
| 1.6 | The pharmacy cannot demonstrate that it makes the required entries for private prescriptions in the private prescription register, so it cannot demonstrate that it meets its legal record keeping obligations. |
Private prescription folder reviewed to ensure all private prescriptions have been written up and staff retrained to ensure all private prescriptions are written up on the day. |
02/10/2026 | 29/09/2026 |
| 1.6 | The pharmacy keeps running balances for certain medicines which require additional records. But it does not regularly audit these balances or investigate discrepancies found between the running balance and the quantity in stock in a timely way. This has resulted in large discrepancies in the different between the running balances and actual pharmacy stock for multiple medicines. And the pharmacy does not make entries for these medicines within the required timeframe. |
Immediate CD balance check carried out and all discrepancies investigated. A weekly balance check carried out with protected staff time to ensure this happens weekly regardless of other workload. A new SOP in place for handing out controlled drugs to ensure handed out prescriptions are returned to the pharmacist immediately and written up as soon as possible after handing out. Also a balance check carried out after each CD entry. |
16/10/2026 | 29/09/2026 |
| 1.2 | The pharmacy does not routinely record near misses (dispensing mistakes that occur before a medicine leaves the pharmacy) with gaps of several months in records seen during the inspection. And the pharmacy team do not always record any dispensing errors (mistakes spotted after a medicine leaves the pharmacy). This means that the pharmacy is less able to demonstrate that it learns from any mistakes. |
Near misses to be routinely recorded and reviewed weekly to enable learning from mistakes. A new dispensing errors book purchased and used to comprehensively record errors that have left the pharmacy. This is to be reviewed monthly to ensure learning from errors and appropriate steps taken to minimise reoccurrences. |
02/10/2026 | 29/09/2026 |
| 3.1 | The pharmacy is not always kept tidy. Although the shop area is tidy, there is excessive clutter on the floor in multiple parts of the dispensary which reduces the space available to the team and makes accessing some of the shelves in the pharmacy more difficult. And it presents health and safety risks including tripping hazards and injury to team members which has previously occurred. |
All clutter on the floor in parts of the dispensary to be immediately cleared. Dispensed medication for all care home to be checked and boxed as soon as dispensed so as to ensure no dispensed medication on the floor. All parts of the dispensary to be tided immediately to ensure no trip hazards and well access to all the shelves in the dispensary. |
02/10/2026 | 01/10/2026 |
Pharmacy inspections
Inspection reports and learning from inspections