| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy hasn’t adequately identified and managed the risks associated with its private prescribing service or when it extemporaneously prepares homeopathic remedies. The pharmacy doesn't have standard operating procedures (SOPs) for its private prescribing service or the manufacture of homeopathic remedies. And it hasn’t reviewed the SOPs it does have for some time to make sure they reflect current practice and are up to date. The pharmacy doesn’t have prescribing policies for each of the conditions covered by its prescribing service. And there’s a lack of procedural evidence to demonstrate effective antimicrobial stewardship and safeguard against the inappropriate use of antibiotics. The pharmacy can’t always show that it checks the identity or health information of individuals accessing the service or that it, with their consent, routinely informs their regular GP or clinician of the prescribing outcome. This raises concerns about the clinical appropriateness and safety of the service. |
The extemporaneous preparation of homeopathic remedies will be stopped with immediate effect. Homeopathic remedies will only be sold over the counter in original packs from the supplier. We will review and strengthen the pharmacy’s SOPs to make sure these are up to date and reflect current practice. We have paused our private prescribing service, until we can demonstrate that we have taken adequate steps to meet this standard. We will put in place Risk Assessments, Prescribing Policies and SOPs for the prescribing service to ensure good governance, assurance and indemnity. Health checks including access to Summary Care Records will be incorporated. Inclusion/exclusion policies will be adhered to and those patients who do not meet the criteria will be signposted and appropriate records made. Initial Risk Assessments will be undertaken and will be reviewed periodically between 3-6 months. If new risks are identified, then we will bring in appropriate changes to our prescribing practice to address them. The above guidance includes matters such as antimicrobial stewardship, training requirements, advertising rules and shared notes to the patient’s GP/clinician. We also make use of leaflets for TARGET antibiotic checklist from a previous PQS and promote it in our team meetings. |
24/02/2026 | 01/03/2026 |
| 1.6 | The pharmacy doesn’t consistently keep adequate consultation records relating to its pharmacist prescribing service and sometimes these lack important details. This raises concerns about the robustness of clinical governance and the ability to review or justify prescribing decisions effectively. The pharmacy doesn’t always maintain appropriate records as required by law. It keeps a log to show who its Responsible Pharmacist (RP) is at any given time, but this often contains the details of the wrong pharmacist and doesn’t include the RP's registration number. The pharmacy doesn’t keep records of the unlicensed medicines it extemporaneously prepares and supplies. It doesn’t complete all the supplier’s details in its controlled drugs register. And its records for the emergency supplies it makes are incomplete or missing. This affects the reliability of the records and makes it harder for the pharmacy to show how it operates safely in the event of a query. |
A new consultation template will be devised for our prescribing service. This will include detailed patient notes and rationale including safety netting, time of consultation and date taken. And reference sources used to consolidate clinical decision making with governance in mind. We will ensure the RP records are accurate, complete and are maintained as required by law. We have received assurance from our IT supplier that the RP records include the pharmacist’s registration number. The extemporaneous preparation of homeopathic remedies will be stopped with immediate effect. We will use established suppliers to fulfil our orders for unlicensed medicinal products (specials). We will ensure we maintain compliant records for the supplies of specials (including certificates of conformity). We will ensure entries made in the CD register meet legal requirements including the supplier’s details (name and address). All emergency supplies made will be recorded in our private prescription register. These records will be maintained as required by law. And they will be chronologically recorded, so that any queries can be retraced. |
24/02/2026 | 01/03/2026 |
| 4.3 | The pharmacy team dispenses prescriptions and sells medicines when there’s no pharmacist at the pharmacy. The pharmacy cannot show that all its medicines it needs to keep in a refrigerator have been stored at the right temperature. |
As a result of the inspection, we have reviewed this concern with all members of the pharmacy team. The appropriate SOP (what to do in the absence of the RP) will be reviewed and adhered to so that no deviation occurs. The pharmacy team will be reminded of this at future team meetings. The Superintendent Pharmacist will review the pharmacy SOPs every 2 years. Staff will be required to read and sign the SOPs to show they have understood and agreed to follow them. The dispensary team will review the SOP for cold storage of medicines and ensure they adhere to it. Two members of the team will be nominated to record the temperature range of each fridge . This will include “High” and “Low” range as of immediate effect. Any deviations will be investigated, and appropriate actions will be taken. |
24/02/2026 | 01/03/2026 |
Pharmacy inspections
Inspection reports and learning from inspections