| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not keep any records of the mistakes it makes or when things go wrong. This makes it very hard to spot any patterns or trends, to learn from them and improve the safety of its services. |
A near miss and dispensing error recording system has been introduced. A near miss log is now maintained and all incidents are recorded and reviewed to identify patterns, support learning and improve patient safety. |
27/03/2026 | 13/03/2026 |
| 1.6 | Although the pharmacy generally keeps the records it is expected to, several of them are incomplete. The pharmacy doesn't keep its records of returned controlled drugs up to date, nor does it include all the information it should in its unlicensed medicines records and its responsible pharmacist record. All of these gaps make it much harder for the pharmacy to look into and resolve any queries that might arise in the future. |
The Pharmacy will conduct a comprehensive audit of all controlled drug records to identify missing or incomplete information. We will establish a new protocol to ensure that all returned controlled substances are recorded accurately and in a timely manner. |
27/03/2026 | 13/03/2026 |
| 4.3 | The pharmacy does not have any recent records or effective procedures in place to identify and remove medicines that have reached their expiry date. It also has inappropriately packaged or labelled stock on its shelves. All of this increases the risk that the pharmacy may supply medicines that are no longer fit for use. In addition, it keeps some specific medicines on open shelves when the law requires them to be stored more securely. |
The pharmacy will introduce a monthly review to ensure dispensary staff consistently check for expired and near-expiry medicines. An updated written SOP has been implemented, and employees have received training to document expiry checks in a logbook. All expired medicines have been removed and disposed of appropriately. Conduct a full audit to identify and correct any medicines that are incorrectly and labelled. Staff will undergo retraining on proper stock handling and labelling procedures. All non-compliant stock has been removed from the shelves and either repackaged or returned to the supplier as appropriate. Introduce a double-check system during dispensing to verify medicine integrity, packaging, and expiry before supply. The procedure has been incorporated into updated SOP. Medicines requiring secure storage has been relocated to compliant storage areas to appropriate locked cabinets. Staff members have completed refresher training on record keeping, stock control, and legal storage requirements. They are also reminded of their legal storage obligations. |
27/03/2026 | 13/03/2026 |
Pharmacy inspections
Inspection reports and learning from inspections