| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have documented standard operating procedures (SOPs) for all aspects of the service. For example, to help manage the risks of prescribing. And to manage the risks in the dispensing process, including the prescriber also dispensing and checking the medicines. And to manage risks in the delivery of medicines to people. |
SOPs are being prepared to reflect all the services the pharmacy provides and the processes undertaken in enabling to provide these services. |
21/05/2025 | 19/05/2025 |
| 1.2 | The pharmacy does not audit or monitor the prescribing and supplies it makes to ensure it provides them safely. And without complete documented prescribing policies and standard operating procedures (SOPs), it does not have access to the right information to be able to conduct any audits effectively. |
Once the SOPs and prescribing policies are in place, the pharmacy will carry out regular audits (yearly) to monitor the prescribing and supplies it makes to ensure they are carried out safely. |
21/05/2025 | 19/05/2025 |
| 1.6 | The pharmacy does not maintain a record of private prescriptions it has dispensed for people, as required by law. |
This is in place now and working appropriately. |
21/05/2025 | 22/04/2025 |
| 1.1 | The pharmacy has an overarching risk assessment (RA) for its service and some risk review documents. But the information is incomplete, and it does not provide enough information to give assurances that the mitigations identified are effective and are regularly monitored. This includes not having a risk assessment for each treatment or medicine. And not documenting the training and skills required to prescribe and dispense these medicines. |
Risk Reviews are being reviewed by the pharmacy and work is in progress to document risk reviews for each treatment and medicine. Training records have been identified and further training has been planned (CPD) and peer to peer discussions to document the skills required to prescribe and dispense the medicines the pharmacy currently offers. |
21/05/2025 | 19/05/2025 |
| 1.1 | The pharmacy provides some information in its overarching RA to help support safe prescribing. But it doesn't have a standalone prescribing policy and the information it does have is insufficient. It does not provide clear frameworks for the prescriber to use to help manage the risks of prescribing for each medicine in each clinical area and for the pharmacy to check supplies are safe and appropriate. This means there is no clear direction on maximum quantities, frequencies of supply and when a supply is inappropriate. |
Prescribing policies for each medicine and condition are being prepared to help support safe and appropriate prescribing including where supply is appropriate or inappropriate and frequency of supplies. |
21/05/2025 | 19/05/2025 |
| 1.6 | The prescriber keeps records of their consultations and any following communications with people about their prescriptions and medicines. But they do not keep accurate records to help justify and reflect on their decisions when they choose not to prescribe for someone. |
System is being put in place to record all consultations which are refused (tech is working on placing a section on customers consultation to input comments on why supply refused and store these customers in a separate section titled “refused supply”. |
21/05/2025 | 19/05/2025 |
| 4.2 | The pharmacy does not have robust systems in place to independently verify the identity of people accessing its services and the information they provide including photographs submitted and about their age. It does not make sufficient checks to ensure that the medicines it delivers are received and in the right condition. |
The pharmacy currently uses Experian ID checker, but after feedback are looking to introduce a mandatory section where users will typically submit an image of one or more of these documents using a smartphone camera (Government Identity Documents (Passport, Driving Licence, National Identity Card) a reliable, physical identity document can be reviewed and the age details noted. The pharmacy has a OBA account with Royal Mail, which generates a tracking number once an order is marked to ship, the pharmacy will implement a checking system where it will check all manifested orders to ensure they have been delivered and received by the customer in the right condition. |
21/05/2025 | 19/05/2025 |
Pharmacy inspections
Inspection reports and learning from inspections