| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have an appropriate standard operating procedure (SOP) describing how authorised team members should supply prescriptions that are ready to collect when the Responsible Pharmacist (RP) is not on the premises. Without this written procedure, there is a risk that medicines could be handed out unsafely and team members may make inconsistent decisions. |
Implement a written SOP for handing out bagged prescriptions when the RP is absent from the premises, in line with Medicines Act 1968, Human Medicines Regulations 2012 and GPhC guidance. The SOP will clearly state when supply is permitted, which trained staff are authorised, what checks must be completed before handout. A poster will be displayed to ensure staff are aware of activities that be undertake we RP is absent. All team members will read, sign and complete competency/training before being authorised. The SOP will be reviewed by the Superintendent and added to the SOP folder with version control and review date. |
30/06/2026 | 25/06/2026 |
| 4.3 | The pharmacy does not always manage its medicines appropriately. It does not have a robust process to check for expired medicines and it cannot always demonstrate that it stores cold chain medicines appropriately to help make sure they remain safe to supply. |
Introduce a documented monthly expiry-date checking process covering all dispensary stock, retail medicines, CDs, fridge items, returns/quarantine areas and emergency supplies. Short-dated stock will be highlighted, rotated, quarantined or removed for safe disposal. Implement a new paper cold-chain procedure: record fridge temperatures at least daily when open, check min/max temperatures, reset the thermometer after recording, document action taken for any excursion, and quarantine affected stock until suitability is confirmed. Provide staff refresher training on expiry checks, fridge monitoring and incident escalation. |
30/06/2026 | 22/06/2026 |