| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.7 | Confidential waste is not being destroyed appropriately. In addition, NHS Smartcards and passcodes are not being used correctly which increases the risk of improper access to people’s health information. |
Confidential waste is destroyed through the use of an approved external contractor who collects and securely destroys all confidential material on a monthly basis. To ensure this process is more clearly evidenced during future inspections, the pharmacy will make the arrangements so that storage of confidential waste is more visible and ensure that documentation relating to collections is readily available for review. The pharmacy has also taken immediate action to address the use of NHS Smartcards and passcodes. All Smartcards are now used strictly by the correct authorised individuals, and staff have been reminded that Smartcards and passcodes must not be shared under any circumstances. Any staff members who do not currently have a Smartcard are in the process of applying for one, and appropriate access will only be granted once this has been issued. |
09/02/2026 | |
| 4.2 | The pharmacy team do not refer to the actual prescription form during the dispensing process when they are assembling multi-compartment compliance packs. This means that there is a greater risk of dispensing errors, and changes to people’s prescribed medication not being identified. |
On the day of inspection, it was identified that not all dispensing tokens were paired as expected; however, this was an isolated incident and did not reflect the pharmacy’s usual practice. Since the inspection, additional measures have been implemented to prevent recurrence. All dispensing tokens are now paired consistently and kept together at all times to ensure they are readily available and clearly identifiable throughout the dispensing process. Staff have been reminded of the importance of maintaining paired tokens and following the agreed procedure at every stage of dispensing. The responsible pharmacist now routinely checks that all tokens are correctly paired during daily operational checks. |
09/02/2026 | |
| 4.3 | Date checking and stock management is not carried out in accordance with the pharmacy’s own standard operating procedures or best practice. This means that there is more chance of out-of-date medication being dispensed, or medication involved in product recalls not being identified. In addition, the pharmacy does not always manage controlled drugs appropriately. |
A robust date-checking system has now been implemented across all medicine storage areas, including the dispensary, refrigerator, CD cupboard, consultation room and OTC displays. Date checks are to be carried out on a regular basis, with results recorded and signed to provide an audit trail. Stock management procedures have also been reinforced to ensure correct stock rotation at all times. Staff have been reminded of their responsibilities when receiving deliveries and restocking. The pharmacy has strengthened its approach to managing product recalls and safety alerts. All alerts received from the MHRA, suppliers or wholesalers are reviewed promptly by the responsible pharmacist, and a recall record is maintained to document actions taken, stock checked and outcomes. With regard to controlled drugs, procedures for patient-returned CDs have been improved. Returned controlled drugs are now recorded immediately upon receipt and placed straight into the CD cupboard to maintain accurate records and ensure the integrity and security of the CD register and storage. All pharmacy staff have been reminded of the relevant SOPs and have received refresher training covering date checking, stock rotation, product recalls and controlled drug management. |
09/02/2026 |
Pharmacy inspections
Inspection reports and learning from inspections