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Pharmacy inspections

Inspection reports and learning from inspections

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Anfield Pharmacy (9010376) - Improvement action plan

GPhC Reference 9010376

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

The pharmacy has a set of written procedures to help manage the risks associated with its services. But the pharmacy has not updated the procedures to reflect the Conditions which were imposed upon its registration. And it does not always inform the pharmacists who work at the pharmacy about the restrictions that are in place. So there is a risk members of the pharmacy team may undertake restricted activities which the pharmacy should not carry out due to the Conditions imposed.

Immediate actions:
- Full SOP review undertaken
- Conditions summary document created and stored in Responsible Pharmacist file
- All regular and locum pharmacists formally briefed and written acknowledgement obtained

Ongoing controls:
- Locum induction checklist implemented
- Quarterly SOP review calendar established
- Monthly governance audit by superintendent

 10/03/2026 19/02/2026
2.2

Members of the pharmacy team have undertaken pharmacy training courses. However, a counter assistant occasionally assists in the dispensing process without the correct training being completed. This does not meet the minimum training requirements for pharmacy support staff to help ensure the team have the necessary skills and knowledge to carry out their work.

Immediate actions:
- Staff member was not on any dispensing duties however she has been made aware to make sure to inform locums of her role as a counter assistant if locums ask for help dispensing.
- Roles clarified and documented
- Staff folder created with essential details, documents and certificates on BrightHR
- Regular team meetings (Huddles) conducted to reinforce scope of practice and address gaps.

Ongoing controls:
- Training matrix created (Bright HR)
- Accredited training pathway identified for all new apprentices
- Monthly competency review schedule introduced

 10/03/2026 19/02/2026
4.3

The pharmacy has Conditions imposed against its registration which prohibit activity involving some higher-risk medicines. But there is evidence that its team members have accepted returned higher risk medicines which is a restricted activity. So the pharmacy cannot demonstrate that it has an effective process and training in place to help ensure the pharmacy only works within the confines for which it holds registration for.

Immediate actions:
- Staff retraining completed
- CD SOP updated

Ongoing controls:
- Weekly superintendent compliance checks

 10/03/2026 19/02/2026
5.1

The pharmacy provides various services, such as flu vaccinations and weight loss services. But it does not have the required equipment to provide these services safely, such as emergency adrenaline or a height chart to calculate BMI. So the pharmacy is not able to demonstrate it has the necessary equipment in order to provide some of its services.

Immediate actions:
- Adrenaline pen and stored in first aid kit
- Height measurement tool was already ordered and waiting receipt has been received and displayed in consultation room

Ongoing controls:
- Expiry monitoring system implemented for equipment and added to Stock date checking SOP

 10/03/2026 19/02/2026
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