| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.3 | The pharmacy cannot demonstrate that medicines are appropriately safeguarded and managed. Medicines are purchased without adequate oversight from the Superintendent pharmacist which has resulted in some higher-risk medicines not being accounted for through available records. The pharmacy does not have adequate governance processes or written procedures in place to monitor stock movements, investigate discrepancies, or identify and manage the risks associated with these medicines. This means the pharmacy cannot provide assurance that medicines are being adequately safeguarded from unauthorised access and managed in a way that protects people from harm. |
-Move specific identified higher-risk medication into CD register and treat as schedule 2 - restrictions on high risk medications so no one can order except the superintendent pharmacist. Weekly CD checks to be done regularly Monthly reports to be generated on high risk medications to review stock usage. Returns procedure to go from manual to electronic to ensure full traceability of drugs. Get double signatures when returning to driver if manual process has to be followed All invoice that have been returned are emailed to superintendent pharmacist to ensure it can be reconciled before end of month Access restricted -Pharmacist locum leaves last with the person locking up -SOP introduced for the management of specific higher-risk medicines. |
05/10/2026 | 14/10/2026 |