| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has failed to maintain up-to-date Standard Operating Procedures (SOPs). SOPs have not been reviewed for several years, contain outdated information, do not reflect current practice, and do not adequately cover all core pharmacy services. This means pharmacy team members may not have access to accurate or current guidance, increasing the risk of inconsistent practice and unsafe service delivery. |
Old sop’s are out of date and we have now downloaded all the pharmacy SOP’s from the NPA and are currently working through them. The SOP’s will be signed by all relevant staff and stored on a computer. |
17/11/2026 | |
| 1.6 | The pharmacy cannot produce complete and accurate Responsible Pharmacist or private prescription records and does not maintain a record of patient-returned controlled drugs. This means it cannot demonstrate compliance with legal requirements or provide assurance that medicines are being managed safely and effectively. |
SI has updated staff on procedures for ensuring that the Responsible pharmacist log is completed correctly, and contacted It supplier to update passwords needed for the Responsible Pharmacist IT process. All relevant staff have been briefed and are aware how to use the system. Dispenser has been trained and can advise any Locums on the procedures required for them to login. SI can has access to the private prescription register on PMR. We used to record patient returns in our old paper based CD register but we no record patient returns on the platform CDRx along with out of date CD’s and quarantined CD stock. |
08/09/2026 | |
| 1.2 | The pharmacy does not have clear procedures for recording and reviewing patient safety incidents and near misses. As a result, it cannot effectively demonstrate how it identifies, learns from, and acts on errors. This may limit opportunities for team members to learn from incidents and implement improvements to reduce the risk of recurrence. |
We already discuss any issues we have in the pharmacy as team meetings but will now document them. We have now implemented procedures to ensure record keeping is kept for patient safety incidents and near misses. We are using the platform CDRx to keep records. Reference to CDrx will also be made in our updated SOP’s . SI currently am registered with the NHS LFPSE website to register any incidents |
08/09/2026 |
Pharmacy inspections
Inspection reports and learning from inspections