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Pharmacy inspections

Inspection reports and learning from inspections

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The Private Pharmacy Clinic (9012397) - Improvement action plan

GPhC Reference 9012397

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

The pharmacy does not fully manage the risks associated with its supplies of medicines for weight management. It is unable to demonstrate that it has adequate procedures in place to corroborate information provided by people to provide assurances that such medicines are safe to supply. It relies largely on information provided by people in a self-reported questionnaire to make prescribing decisions virtually. And verifying people’s weight when making a prescribing decision about weight management medicines by using a pre-recorded uploaded video is not sufficient and not in line with current GPhC guidance.

• Clarification: The videos submitted during form submission are not pre-recorded but
are recorded and uploaded in real-time at the time of submission. This ensures
authenticity and accuracy in weight verification.
• Implement a live video consultation process for further verification where necessary.
• Introduce a two-tier approval system:
o Step 1: Match patient details with a photo ID to confirm identity.
o Step 2: If the patient is classified as high risk (e.g., BMI concerns,
comorbidities), an additional verification check will be required before approval.
• Require a clinician-confirmed weight history or GP records for additional verification
where needed.

 31/03/2025 01/05/2025
1.6

The pharmacy cannot show that it keeps all the records it needs to for the safe provision of its services. Its Responsible Pharmacist record is incomplete. And its records about its weight management service are not made contemporaneously and lack enough detail to show that medicines are supplied safely. For example, its records do not show that it has properly considered inclusion or exclusion criteria or has provided appropriate safety netting advice to people taking weight management medicines.

Website team is actively implementing changes to the website to incorporate a
comprehensive Patient Medication Record (PMR) system to ensure that patient data
is recorded in real time.
• Prescribers have been instructed to document detailed clinical notes for each
prescription, including:
o Inclusion/exclusion criteria assessments for all prescriptions.
o Documented clinical justifications for prescribing weight management
medicines.
o Patient safety netting advice, including potential side effects and follow-up
requirements.

 31/03/2025 01/05/2025
4.2

The pharmacy cannot provide adequate assurances that its services are delivered safely and effectively. It is unable to demonstrate that it has reliable systems to capture all the relevant information needed for the healthcare professional to make an informed decision about whether it is safe to provide medicines, including those for weight management, to people.

Develop an automated flagging system for risk factors such as high BMI,
comorbidities, or multiple medication use, triggering additional review.
• Introduce peer-review case discussions among prescribers to assess complex cases.
• Consent to share records with GPs is being integrated into the website questionnaire
submission process, ensuring seamless and secure information sharing while
enhancing patient safety.

 31/03/2025 01/05/2025
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