| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy’s standard operating procedures are not up to date and do not accurately reflect current working practices. Team members are not always able to demonstrate that they have read, understood, or are consistently following the procedures. This increases the likelihood that risks associated with the delivery of pharmacy services are not being adequately managed. |
The standard operating procedures are moving to an online platform. Procedures will reflect the actual working practices and will be signed by each staff member. |
29/04/2026 | 27/03/2026 |
| 1.6 | The pharmacy does not maintain accurate records. The Responsible Pharmacist log, 'specials' records and records relating to patient returned higher‐risk medicines are sometimes incomplete. This means that the pharmacy may not be able to account for medicines or be able to demonstrate what has happened in the event of a query. |
Responsible Pharmacist log is now recorded on a different platform. It is being used daily and accurately by all RP’s. I am checking this on a daily basis. Specials records are held in a separate file and a separate area has been created for specials prescriptions. Patient returned High-risk medicines are now recorded immediately and destroyed immediately or at the earliest opportunity within 7 days as per the SOP. If not destroyed immediately they are recorded, bagged, sealed and marked as “patient returns – CAN be destroyed – NOT to be used for dispensing”. |
29/04/2026 | 27/03/2026 |
| 4.3 | The pharmacy gets its medicines from reputable suppliers. But it cannot demonstrate that it monitors the temperature at which refrigerated medicines are being stored. Or that returned and expired higher‐risk medicines are being suitably managed. |
Fridge temperature logs are maintained on a daily basis. Staff have been assigned the role and confirmation these have been done is sent to me on a daily basis. The temperature is logged online and reset. |
29/04/2026 | 27/03/2026 |
Pharmacy inspections
Inspection reports and learning from inspections