| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not routinely record near miss errors identified during the dispensing process. And there are no arrangements in place to learn from things that go wrong. |
1. Introduce a near miss log to record all near misses. These will then be reviewed on a regular basis to ensure that all team members learn from things that go wrong, and future re-occurrences are avoided. 2. Team meetings will be carried out regularly to review near misses and to ensure that all team members are aware of these and how future re-occurrences can be avoided. 3. Near misses will be reviewed more frequently when there is a serious near miss. Standard operating procedures (SOPs) will be reviewed in light of any serious near miss and amended accordingly if required. |
21/03/2025 | |
| 1.3 | Team members are not fully clear on their roles and responsibilities, or what activities they can undertake in the absence of the responsible pharmacist. There is no responsible pharmacist notice displayed to show who is responsible for the safe and effective running of the pharmacy. |
1. Appendix 2 and 3 of SOP 20 Roles and Responsibilities of Pharmacy Staff is to be fully completed to ensure that all staff are competent for all roles that are undertaken. 2. All staff to read and sign all SOPs and the Responsible Pharmacist (RP) SOP to ensure that SOPs are being followed at all times. 3. A Responsible Pharmacist notice will be on display to show who is responsible for the safe and effective running of the Pharmacy. 4. All staff will read and sign the SOP for Operating in the Absence of the Responsible Pharmacist so that they are aware of the activities that can and cannot be undertaken in the absence of the RP on the premises. |
21/03/2025 | |
| 1.6 | The pharmacy does not maintain all the records as required by law, such as responsible pharmacist records. |
1. A Responsible Pharmacist notice will be on display to show who is responsible for the safe and effective running of the Pharmacy. 2. A Responsible Pharmacist Log will be put in place and recorded daily to show who was responsible for the safe and effective running of the Pharmacy. |
21/03/2025 | |
| 2.2 | Team members do not have the appropriate qualification training for the activities they undertake. |
1. All relevant staff will be enrolled on an appropriate training qualification which will be completed in a timely manner. |
21/03/2025 | |
| 4.3 | The pharmacy does not manage some its medicines safely, including effectively checking medicines' expiry dates, recording fridge temperatures and ensuring medicines which it removes from the manufacturer's original packaging are labelled appropriately. |
1. As discussed during the inspection, medicines that are being picked to be distributed to spoke Pharmacies are date checked before sending to the spoke Pharmacy. These medicines were redundant stock that were not used by the spoke Pharmacy and were transferred to the premises for onward distribution to another one of our Pharmacies. 2. All stock within the premises will be date checked more robustly using a date checking matrix, and short dated stock of less than one year will be double stickered. 3. Fridge temperatures will be recorded daily, and any temperatures out with 2 and 8 degrees Celsius will be investigated and dealt with accordingly by the Responsible Pharmacist. 4. Stock that has been removed from the original pack for use in our automated dispensing machine in our second hub pharmacy has the original pack placed inside the bag to identify the product, batch number and expiry date. An original pack will also be taped to the front of the bag to ensure that bags are labelled correctly. |
21/03/2025 |
Pharmacy inspections
Inspection reports and learning from inspections