| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy has records related to the pharmacy services it provides. But the responsible pharmacist record contains only the time the responsible pharmacist began their tenure, and there are gaps in the records across several days. Members of the pharmacy team do not record details of who the prescriber was for unlicensed ‘specials’ and private prescriptions. The register for the return of higher-risk medicines to the pharmacy is unreliable and does not match what is stored on the premises. So the pharmacy is unable to demonstrate its records are always accurate. |
The pharmacy team has been retrained to complete all existing records fully and consistently. Responsible Pharmacist entries will now be checked to ensure start and end times are recorded with no gaps. Prescriber details for unlicensed specials and private prescriptions will be entered on the PMR. The returns register for higher-risk medicines will be reviewed against physical stock, corrected, and will be cross checked monthly to maintain accuracy. |
10/09/2026 | 15/09/2026 |
| 1.2 | The pharmacy does not routinely record its mistakes, and the pharmacy team are unable to demonstrate how they learn from when things go wrong. So the team are unable to show how they are reviewing their services to improve their work. |
The pharmacy has implemented a formal near miss and dispensing error recording process. All team members have been trained to document mistakes at the time they occur using a standardised log. A monthly review meeting has been introduced to analyse trends, identify root causes, and agree actions to prevent recurrence. Learning outcomes will be shared with the whole team. |
10/09/2026 | 09/09/2026 |
| 4.3 | The pharmacy has some processes to check its stock medicines remain fit for purpose. But the team do not always record when they have checked the expiry date of stock, and some stock was found to have expired. Some stock medicines are stored in unlabelled containers. This does not meet minimum labelling requirements and increases the risk of error. |
A structured date checking schedule has been introduced, with each section assigned to named staff and recorded on a new expiry check log. All expired stock has been removed, and the team has been retrained on proper stock rotation. Any unlabelled containers have been replaced with correctly labelled packaging that meets legal requirements. Monthly spot checks will be carried out by the RP to ensure ongoing compliance. |
10/09/2026 | 09/09/2026 |
| 5.2 | The pharmacy has a range of measures for reconstituting antibiotic medicines. However, it does not have a measure for volumes less than 10ml. So the pharmacy does not have all the necessary equipment in order to delivery its services safely and effectively. |
The pharmacy has purchased graduated glass measuring cylinders suitable for volumes of 100ml and a smaller one that can measure in 1ml increments. The team has been trained on correct use and cleaning of the new equipment to ensure safe and accurate preparation of antibiotic suspensions. |
10/09/2026 | 09/09/2026 |
Pharmacy inspections
Inspection reports and learning from inspections