| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.7 | The pharmacy team currently store information in such a way that it could be seen by non-pharmacy staff. So unauthorised access to people's private information is possible. |
Door between Pharmacy and Surgery will remain locked so surgery staff will no longer be able to enter the Pharmacy. A poster has been put up for Pharmacy staff as a reminder that the door must remain locked. Jigar will arrange for separate mobile line for communication with surgery. Surgery has been informed. |
17/04/2025 | 15/04/2025 |
| 1.6 | The pharmacy team do not maintain all necessary records for the safe provision of pharmacy services. The date checking and fridge temperature records were incomplete. |
Staff reminded of legal requirement to complete pharmacy records. PMR updated to require Fridge log and Responsible Pharmacist log to be completed before any other actions can take place. Paper RP log also being used. Paper date checking matrix initiated. |
17/04/2025 | 15/04/2025 |
| 1.1 | The pharmacy team do not keep regular records of near miss mistakes. This means that they are not able to demonstrate learning from previous incidents. |
1.1 The pharmacy team do not keep regular records of near miss mistakes. This means that they are not able to demonstrate learning from previous incidents. Paper based near miss log implemented. Pharmacy team informed on importance of logging near misses. Sneha to review compliance in 2 weeks. Logs to be sent to Sneha at the end of every month and Jigar to discuss and share with Pharmacy team. 10 working days from receipt of the finalised report Jigar – Pharmacy Manager 20/02/2025 Near miss logs. |
17/04/2025 | 15/04/2025 |
| 1.2 | The pharmacy team do not have up-to-date written procedures for all of the activity carried out within the pharmacy, including automated dispensing technology. |
SOP created for use of automated Dispensing Robot. Other SOPs in process of being reviewed. |
17/04/2025 | 15/04/2025 |
| 2.2 | There are members of the pharmacy team that are not on a training course suitable for their role. |
Nirav and Mili have been enrolled onto NPA’s Medicines Counter and Dispensing Course. |
17/04/2025 | 15/04/2025 |
| 5.1 | The pharmacy team did not have access to the necessary equipment to accurately measure liquids. |
Stamped measuring cylinders have been ordered, and non-marked equipment removed from Pharmacy. |
17/04/2025 | 15/04/2025 |
Pharmacy inspections
Inspection reports and learning from inspections