| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 3.2 | The pharmacy has a consultation room. But the door is constructed of glass, and the blind does not provide a suitable degree of privacy when the room is in use. So people may not always have access to a confidential space for the pharmacy services provided. |
This will be blanked off with frosted glass or other suitable opaque material. |
20/05/2026 | 22/04/2026 |
| 4.3 | The pharmacy does not have a formal date checking process in place and expired medicines are not removed from stock medicines. So it is unable to demonstrate how it suitably manages its medicines to make sure they are safe to supply. |
A quarterly date checking rubric will be introduced in store. |
20/05/2026 | 22/04/2026 |
| 4.2 | The pharmacy supplies some medicines in multi-compartment compliance packs. But it does not make sufficient records when there are changes to the medicines people are taking which may increase the risk of errors occurring. It does not have a robust audit trail when compliance packs are assembled in advance of a prescription being received, and ensure there are enough sufficiently trained staff who understand how the service operates. So, the pharmacy is unable to demonstrate it has considered and managed all of the risks involved with the service to ensure it is provided safely. |
A new system comprising of a numbered 4 weekly system is in place. All information is now known before dispensing. We will request a blister pack prescription 2 weeks in advance so we have enough time to work through this as opposed to the current 1 week. Information is gathered with liaising with the surgery and checking for DMS All prescriptions are checked by the pharmacist before getting to the ACT or Dispenser for clinical suitability. After this, the blister pack can then be made up. |
20/05/2026 | |
| 1.2 | The pharmacy does not have a robust process to review when mistakes occur in order to identify improvements. Whilst individual members of the pharmacy team take some action to help make improvements, the pharmacy is without an embedded process. This may risk mistakes going unnoticed, and insufficient action being taken to help reduce the likelihood of similar mistakes. |
We will introduce a Pharmacy Incident and Error Report System (PIERS) in the form of CDRx and all members of staff should report near misses. This will be reviewed by myself monthly and data will be compiled to work out the most common mistakes. Any event that reaches the patient will trigger a full scale Root Cause Analysis as to identify any underlying causes and to help implement preventative measures. |
20/05/2026 | 22/05/2026 |
| 1.6 | The pharmacy does not maintain the necessary records it is required to keep. The responsible pharmacist record does not contain the details of when the pharmacist ceases their responsibility to help show when a responsible pharmacist is present. The private prescription records do not always contain the details of the prescriber. And records for the supply of unlicensed specials do not contain information about who the medicine was supplied to So the pharmacy may not have accurate information to refer to in the event of a query or a concern. |
An Electronic register is in place, but an alarm will be set daily so the RP signs in and out. All staff will know how to teach the RP how to sign in and out of the system. Every private prescription will have the quantity, drug, strength, dose and prescriber added as per MEP. |
20/05/2026 | 22/04/2026 |
| 1.1 | The pharmacy has a set of written procedures. However, they are written by an external company and have not been reviewed to ensure they accurately reflect the processes that its team members follow. So, the pharmacy is unable to demonstrate they have sufficient measures in place to help manage the risks associated with the pharmacy’s services. |
The Informacist provides us with a full set of SOP’s. These will be reviewed by myself as to what is relevant for which member of staff and which isn’t. I will also introduce new SOP’s where appropriate. |
20/05/2026 |
Pharmacy inspections
Inspection reports and learning from inspections