| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not monitor the risk of providing all of its services appropriately as it does not always record the mistakes it makes when dispensing medicines. This hinders learning and means there is an increased risk of repeated mistakes occurring. |
Near misses and medication incidents are now recorded and investigated systematically. Staff involved in such incidents are encouraged to log and reflect on their actions, creating a culture of accountability and learning to prevent recurrence. |
12/05/2025 | |
| 4.3 | The pharmacy does not manage all of its medicines appropriately. Some multi-compartment compliance packs containing higher-risk medicines are not stored securely. And some medicines are not stored safely within the manufacturers original packing. The pharmacy has a record to help its team complete regular checks of its stock medicines. But this record does not include all areas where medicines are held and has contributed to date-expired stock going unidentified. This increases the risk of the pharmacy supplying an out-of-date medicine. |
We have taken immediate steps to safeguard high-risk medications by ordering new high-security cabinets, which are currently in the process of being installed. In the interim, no high-risk medications are being stored outside of designated secure areas, ensuring full compliance with safety protocols. Only the correct quantity and medications required for dosette boxes are used. Any excess medication that is removed from blister packs is not reused, in line with good practice for medicine safety and hygiene. We have fully implemented a date-checking matrix across the pharmacy to proactively identify and manage medications approaching their expiry dates. All medications have been systematically organised into designated sections, each assigned within the matrix. This matrix is accessible to all pharmacy team members via the PharmSmart portal, and colleagues are required to sign off on their completed expiry checks, ensuring shared responsibility and traceability. |
12/05/2025 |
Pharmacy inspections
Inspection reports and learning from inspections