| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has written procedures for the off-site dispensing of multi-compartment compliance packs which do not reflect current practice. And there is no written procedure detailing the way in which prescriptions are clinically and accuracy checked when working with an accuracy checking technician. |
The SOPs have been updated to reflect current practice, including the way in which prescriptions are clinically and accuracy checked whilst working with an ACT. |
16/01/2026 | 16/12/2025 |
| 4.3 | The pharmacy does not store and manage all of its medicines as it should, including higher risk medicines. And it removes some medicines from the manufacturer’s original packaging and does not correctly label the containers with batch number and expiry date. So, the team cannot effectively action safety alerts and drug recalls and cannot effectively check expiry dates of these medicines. |
• All drugs allocated to their correct storage areas. |
16/01/2026 | 16/12/2025 |
| 4.3 | The pharmacy does not have an effective procedure to check expiry dates of medicines it stores outside of the automated dispensing system. And there are out-of-date medicines on the shelves. So, this means there is a risk people may receive medicines which are not fit to supply. |
• Despite regular date checking, there were sections overlooked due to the shelves being re-arranged. Those sections missed have been date checked as well as a full shop date check being under way. |
16/01/2026 | 16/12/2025 |
Pharmacy inspections
Inspection reports and learning from inspections