| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 2.1 | The pharmacy has seen a large increase in its level of business recently. And it cannot demonstrate how it monitors or reviews the increases in workload and staffing levels. So it cannot provide assurances that its services continue to be delivered safely and effectively. |
We have adopted a rota system through a system called BrightHR. Each member of staff is sent a rota which matches the need of the business. Since the inspection we have also taken on a further 8 members of staff. This will result in the pharmacy delivering services accurately and effectively. |
23/11/2026 | 02/11/2026 |
| 2.2 | Team members perform duties that they are not appropriately qualified or trained for. The pharmacy has number of team members undertaking dispensing duties that have not been enrolled on an appropriate training course. |
Several staff members have been enrolled onto the Buttercups dispensing course. A folder has been prepared of those members of staff enrolled on this course. For those members of staff that have completed their course certificates will be in the folder. We are also looking at support staff courses for those not involved in the day to day dispensing. |
23/11/2026 | 02/11/2026 |
| 2.3 | The Superintendent Pharmacist does not have sufficient oversight, support or capacity to monitor how the pharmacy provides its services. They are not empowered to exercise their professional and legal obligations in the best interest of patients and the public. |
As the pharmacy has increased its items the focus had been on delivering and maintaining schedules that the medication was sent on time. This naturally led to me spending less time on the SI side of the tasks. An immediate change that has been made is that additional support is given to me at least 3 to 4 times in the week by a locum pharmacist. On two/three days they will be RP allowing me to step away from the day to day checking and running of the pharmacy so I can concentrate on other tasks and have a better oversight of the running of the pharmacy. Getting a locum in was a short-term fix but the plan is to get a full time pharmacist in who will be the RP everyday they are here so I can support rather than be involved in the day to day running. |
23/11/2026 | 02/11/2026 |
| 4.3 | The pharmacy does not have enough capacity to store all of its higher-risk medicines in line with Safe Custody Regulations. And when these medicines are returned to the pharmacy for destruction, they are not safeguarded against unauthorised access. And some medicines are not suitably denatured before disposal in line with requirements. |
We are changing the process of how we are managing our returned waste CDs. In the returns room which is secured by a lock requiring a pin number we will add 2 or 3 controlled drug cabinets to the concrete wall. When the CDs get returned to the pharmacy a dispenser will then separate these and place them into the CD cabinet. A list has been printed and stuck on the wall of all the CDs that require safe custody when the medication has been returned to us. At the same time the dispenser will also complete the returned/destroyed CD book ready to then destroy by one of our pharmacists. The keys will remain with the RP. It was also identified that when CDs are ordered and enter the pharmacy space was an issue and the entries were not always done on time especially when the SI was not on duty. Two large CD cabinets have been ordered from Denward delivery has been confirmed for this week Wednesday 4th November. These will then be fitted and the old ones placed into the returns room. |
23/11/2026 | 02/11/2026 |
| 1.3 | The pharmacy's team members are not clear on the tasks they can and cannot undertake when there is no Responsible Pharmacist present. |
Each department with the pharmacy will be shared a PP presentation. Some have already read this and its titled “Welcome to CQP” this is the induction pack given to all new staff. On top of this we will also include the responsibilities of the responsible pharmacist and what can and can’t do. This will be sent by email and a signature sheet obtained that everyone has read it. |
23/11/2026 | 02/11/2026 |
| 1.6 | The pharmacy does not maintain complete and accurate records for its controlled drugs (CDs) and Responsible Pharmacist records in line with statutory requirements. The pharmacy is significantly behind in entering the supplies it has made into the register. Which means records are not accurate or up to date. |
The records have now been updated for both the RP register and the Controlled drugs. A pharmacist was always onsite but as you saw on the day the pharmacist who worked the shift did not sign in. We have an RP process in place now and this information is found in a folder next to the RP book. The CDs have all been entered. We are in the process of |
23/11/2026 | 02/11/2026 |
| 1.2 | Pharmacy team members do not always record the mistakes they make during the dispensing process. This means that they are missing the opportunities to learn and improve from such events. |
Two processes are now taking place within the pharmacy. One is the near miss log, and the other is concerns and feedback post delivery of the residents medication. The near miss log is now in a monthly folder near the RP book. This is clearly divided and near miss are logged onto the pages. At the end or beginning of the month the SI will analyse the mistakes made and share any wider learning with the team. This will be done as a whole or will be targeted at specific teams. The findings and evaluation will be kept in the near miss folder. The second process will be concerns and feedback post-delivery of the resident’s medication. Paula Allen our Care partnerships manager has taken on this responsibility. Concerns and feedback will be noted each week and then placed onto a RAG system where we can identify if it was red, amber or green and then share any relevant learnings. This will be done on a weekly basis. The folders will be kept as with the near miss log monthly and organised. |
23/11/2026 | 02/11/2026 |
Pharmacy inspections
Inspection reports and learning from inspections