| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not monitor the quality or safety of its services through regular audits. So it can't show that prescribers continue to follow the procedures it has put in place to keep prescribing safe. And by not completing these reviews, the pharmacy has missed opportunities to identify areas for further improvement. |
All private services undertaken by the pharmacy staff are to undergo 3 -6 monthly audits. Each service will be reviewed in rotation by picking a sample of the data in the service and comparing against SOPs ensuring correct pathways/guidelines are being followed. The audit will be risk assessed to understand any concerns or shortfalls in the services and asses any risk/harm which may be present to the user. |
12/05/2025 | |
| 1.2 | The pharmacy doesn't follow its own reporting procedures when managing dispensing mistakes. This hinders learning and increases the chance of a similar incident occurring. |
Ensure all dispensing errors are recorded on the patients PMR. This report then to be analysed and assessed by the pharmacy team with an action plan of how to prevent similar or the same error happening again. Next steps to be discussed as a pharmacy team and relevant notes added around dispensary to minimise errors occurring again. |
12/05/2025 | |
| 4.3 | The pharmacy doesn't make checks to ensure weight loss medicines requiring cold storage are appropriately packaged and are delivered in a timely manner to ensure they remain safe for people to use. |
Change Ice packs used to gel packs, complete once a month audit trail using a temperature gauge to ensure cold chain is maintained. Audit trail of all 24 hour tracked deliveries of cooled medications to ensure arrival within the dedicated time frame to ensure integrity of product. |
12/05/2025 |
Pharmacy inspections
Inspection reports and learning from inspections