| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have complete and up to date risk assessments for the treatments provided, including the supply of Mounjaro injections for weight loss. It does not review its risk assessments annually, and it has not reviewed them since the update to the GPhC's Guidance for providing services at a distance. |
Risk assessments will be completed for every service that is provided to ensure that all potential risks associated are identified, assessed and documented. Risk assessments will be reviewed on a quarterly basis or sooner in the event of any service incidents. |
05/08/2025 | |
| 1.1 | The pharmacy does not have a complete and up-to-date set of written standard operating procedures for the services it provides. And although some new procedures have been written, they have not yet been read by the team and embedded into ways of working. |
A complete audit of existing standard operating procedures has been completed. All remaining SOPs are being reviewed, and additional SOPs will be developed that are reflective of the current business model |
05/08/2025 | |
| 1.1 | The pharmacy does not have a complete set of up-to-date prescribing policies for the services provided. The policies it does have are not readily available for its prescribers and other team members to use and refer to. It is not clear from its policies who is responsible for completing and documenting ongoing monitoring checks required for each treatment, for example blood pressure checks. |
Prescribing policies for all therapeutic areas are being reviewed and updated. Separate policies will be produced for Weight Loss, Erectile Dysfunction, Hair Loss and Premature Ejaculation. Policies will be drafted by the Superintendent Pharmacist with input and oversight from all prescribers and will incorporate all current evidence-based guidance for each service provided. Prescriber peer review meetings will be established, and all prescribing policies will be reviewed on a quarterly basis or sooner in the event of any service incidents. |
05/08/2025 | |
| 1.2 | The pharmacy has stopped completing regular audits, and has not completed any since the GPhC updated its Guidance for providing services at a distance. And it is difficult to complete meaningful audits when written procedures do not give up-to-date guidance on expectations around independent verification of clinical information, two-way communication with patients and direction on suitability of patients' BMI for different ethnic backgrounds. |
A comprehensive range of audits will be introduced as part of a wider patient safety and quality improvement initiative. Audits will be used to share learning, ensure compliance with current regulation, clinical guidelines, prescribing policies and ultimately improve patient care. |
05/08/2025 | |
| 4.2 | The pharmacy doesn't always independently verify clinical information provided by the patient, particularly for the weight loss service. This means people may receive treatment which is not suitable and safe for them to take. |
Updated clinical guidelines are being produced for all therapy areas and will incorporate all the current guidance. Prescribing policies will mandate all required clinical information to be obtained in advance of any prescribing decisions. Independent verification of a patient’s BMI is now mandatory with the requirement for video calls for every new patient, details recorded on the patient's clinical record. Existing patients will be subject to the same requirements with mandatory video calls being conducted at the 3-month and 6-month review. Quarterly audits will be undertaken by the Superintendent Pharmacist to ensure compliance with policy. |
05/08/2025 | |
| 4.2 | The pharmacy cannot confirm the packaging it uses to deliver medicines requiring cold storage keeps them at the required temperature during the journey. So, people may receive medicines with reduced shelf life. |
Standard Operating Procedures will be developed to include all aspects of cold chain management including receipt, storage, packaging, dispatch and delivery processes with clear temperature and monitoring across the entire cold chain. A full temperature mapping audit of the existing supply chain will assess the performance of current packaging to provide assurance that the cold chain is being maintained. |
05/08/2025 |
Pharmacy inspections
Inspection reports and learning from inspections