| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | The pharmacy does not always store its stock medicines appropriately. Several packs of medicines were found containing mixed batches, or the containers they were in were unlabelled. And loose strips of tablets were found on the dispensary shelves. This increases the risk of a dispensing error happening, and would make date checks or dealing with product recalls more difficult. |
Immediate dispensary stock review • A full shelf-by-shelf check of all dispensary stock is being carried out. • Loose strips of tablets are being removed from the shelves. Strips that can be returned to their original pack with a matching batch number and expiry date go back in that pack. Any that cannot be identified with certainty are quarantined and destroyed as pharmaceutical waste. • Packs with mixed batches are being separated so each pack holds one batch and expiry date only. Any stock whose batch or expiry cannot be confirmed is quarantined and destroyed. • Unlabelled containers are being removed. Medicines are kept only in their original manufacturer packaging. Ongoing stock control • Clear rule for all staff: never mix batches, never leave loose strips, and keep every part-pack in its original box, marked as a part-pack. • Date-checking matrix: the dispensary is divided into sections so that all stock is checked at least every 3 months. Each check is recorded and signed. Short-dated stock is stickered. • Drug alerts and recalls are actioned promptly. The action taken is recorded. Training and monitoring • The stock management SOP is being updated. All staff will read it and sign to confirm they understand it. The team is briefed on why these steps matter for dispensing accuracy and for handling recalls. • The pharmacist will spot-check the shelves weekly for 3 months, then monthly, and record findings on a checklist. Issues are corrected immediately and discussed with the team. |
26/11/2026 | |
| 4.3 | The pharmacy cannot sufficiently demonstrate that it keeps its medicines requiring cold storage at the right temperatures. It does not record daily temperatures of both fridges, and not all staff know how to reset the thermometers on the fridges. The maximum temperatures on each fridge were out of range during the inspection. So, staff have less assurance that the medicines in the fridges are fit for purpose. |
Daily temperature records • Each fridge has its own temperature record sheet. The current, minimum and maximum temperatures are recorded every day the pharmacy is open, at a set time (start of the day). The thermometer is then reset, and the staff member signs and dates the entry. • The Responsible Pharmacist checks the record each day. The Pharmacist Manager reviews it weekly. Records are kept for inspection. Equipment • Both fridge thermometers are being checked and replaced with calibrated digital minimum/maximum thermometers where needed, with data loggers to be considered. • The fridges are being checked to ensure they are not overstocked, air can circulate, door seals work and stock is kept away from the cooling plate. Each fridge will be serviced if needed. Out-of-range readings • Readings found to be out of range during the inspection are being investigated. Affected stock is quarantined pending advice. Manufacturers are being contacted to confirm whether the stock can still be used, and the outcome will be documented. Any stock that cannot be used will be destroyed. For vaccines, Green Book (Chapter 3) guidance will be followed and the local immunisation team informed where required. • Out-of-range procedure: re-check and reset the thermometer, tell the Responsible Pharmacist, label stock 'Do not use', seek manufacturer advice, record all actions, and arrange a repair if the fridge is faulty. Training • All staff are given hands-on training in reading, recording and resetting the thermometers, and each person is signed off as competent. Simple laminated instructions are displayed on each fridge. • The cold chain SOP is being updated. All staff will read it and sign to confirm they understand it |
26/11/2026 | |
| 1.2 | The pharmacy cannot sufficiently demonstrate that it records and learns from any dispensing mistakes it makes. For example, it cannot show that it records mistakes which are identified before the medicine is handed out (near misses). So, this makes it harder for the pharmacy to identify any patterns or trends. And could mean it is missing out on opportunities to make the pharmacy's services safer. |
Near-miss recording • A near-miss log is being introduced at the checking bench. Every near miss is recorded at the time it is found. • Each entry records the date and time, the medicine involved, the type of error (e.g. wrong strength, wrong drug, wrong quantity, wrong label), possible contributing factors and the action taken. • The team member who made the error corrects it and records it themselves, so they reflect on it and learn from it. The pharmacist checks that the entry has been made. Dispensing errors (reaching the patient) • Recorded on the pharmacy's incident report form, reported to the Superintendent and reported nationally via the NHS Learn from Patient Safety Events (LFPSE) service. • A root-cause review is completed and the learning is shared with the whole team. Monthly patient safety review • At the end of each month the Pharmacist Manager reviews all near misses and errors to identify patterns and trends (e.g. look-alike/sound-alike medicines, similar packaging, busy periods). • Agreed actions are written up on a Patient Safety Review form, for example separating look-alike medicines or adding shelf-edge caution labels. Their effect is checked at the next review. • Findings are discussed at a team briefing. Staff sign to confirm they have attended. Procedures and training • The incident and near-miss management SOP is being reviewed and updated. All staff will read it and sign to confirm they understand it. • Records (logs, reviews and signature sheets) are kept in a patient safety folder and available for inspection |
26/11/2026 |
Pharmacy inspections
Inspection reports and learning from inspections