| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have written standard operating procedures (SOPs) that reflect all the activities the pharmacy carries out. The SOPs it does have, have not been signed and reviewed by the superintendent pharmacist. There is also no evidence that team members have read them. This means the pharmacy cannot demonstrate that its team members know how to work safely and effectively. |
Hub SOPS have been supplied by the third-party supplier of the pharmacy's dispensing system. Further SOP’s have been prepared and will be confirmed and signed by Superintendent and all staff. |
19/02/2025 | 25/02/2025 |
| 1.3 | Team members are not clear about the activities they can and cannot do in the absence of the responsible pharmacist. And the pharmacy's SOPs do not define individual roles and responsibilities of team members. This increases the chances team members undertake tasks for which they don't have the right skills and qualifications or carry out tasks without the appropriate supervision. |
Clarifying what can be done as per the updated SOP’s will explicitly explain what activities are allowed. A list of acceptable processes will also be available to further emphasise the processes. |
19/02/2025 | 24/02/2025 |
| 1.6 | The pharmacy does not make or keep responsible pharmacist (RP) records. And so it cannot show who has been responsible for overseeing the pharmacy's activities when the pharmacy is open. |
The pharmacy will make the necessary RP records on an electronic register. |
19/02/2025 | 24/02/2025 |
| 1.7 | The pharmacy does not always separate confidential waste from general waste. So, it cannot show that personal information is always protected against inadvertant disclosure. |
Re-emphasise the need to segregate confidential waste from regular waste. Shredder purchased for Hub so that confidential waste can be destroyed immediately to reduce the risk of it being placed in with regular waste by mistake. |
19/02/2025 | 24/02/2025 |
| 4.4 | The pharmacy cannot show what action it has taken about previous safety alerts and recalls. This means the pharmacy cannot demonstrate that it responds appropriately to safety alerts and recalls to ensure people only receive medicines which are suitable for use. |
A supplementary email address to be created for alerts to be sent to as well as installing pharmdata.co.uk on the Hub computers to see alerts as they happen. This means they can be acted on as appropriate. Alerts received in Spoke pharmacy to be sent to Hub email as well. |
19/02/2025 | 24/02/2025 |
Pharmacy inspections
Inspection reports and learning from inspections