| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy is not identifying and managing several risks associated with its services. Staff are |
All SOPs to be reviewed again by staff. Time has been allocated for staff each week to complete SOPs in a gradual and thorough manner to improve understanding with the aim of all SOPs to be completed over a 3 week period. |
07/05/2025 | 18/05/2025 |
| 1.2 | The pharmacy does not have a robust process in place to manage and learn from incidents. There is no evidence that staff are routinely recording details about incidents and complaints in line with the pharmacy's documented procedures and there are no near miss mistake records. This means that there is limited evidence of remedial activity or learning occurring in response to mistakes. |
Patient safety review folder to be created and actioned and reviewed by all staff weekly. Near miss recording process has been reviewed and measures taken to implement new process of recording all errors. Dispensers to enter their own errors with the pharmacist overseeing and reviewing at the end of each week. |
07/05/2025 | 18/05/2025 |
| 1.3 | The pharmacy's team members do not know which activities can or cannot take place in a closed pharmacy that provides its services at a distance and newer members of staff do not know which activities can take place in the absence of the responsible pharmacist (RP). This is unsafe. |
Newest member of staff to review SOPs again and understanding to be reiterated by RP/Superintendent pharmacist. All SOPs to be reviewed again by staff. Time has been allocated for staff each week to complete SOPs in a gradual and thorough manner to improve understanding with the aim of all SOPs to be completed over a 3 week period. In particular as a team we have reviewed all with staff the process surrounding providing essential services as a distance selling pharmacy. Newest member of staff to be enrolled on to buttercups dispensing course and senior member of staff to be enrolled on Accuracy Checking for Dispensing Assistants with a view to potentially enrolling on Pharmacy Technician Course in the future. |
07/05/2025 | 18/05/2025 |
| 4.4 | The pharmacy team has not been dealing with and appropriately actioning all the drug alerts issued by the Medicines and Healthcare products Regulatory Agency. This means that the pharmacy could have potentially supplied affected batches of medicines. |
All drug alerts that had been missed in the past 6 weeks have been actioned and is now being actioned regularly by all staff. |
07/05/2025 | 18/05/2025 |
| 4.1 | The pharmacy is advertising services on its outside fascia which it does not provide. This is misleading members of the public. |
Measures are being taken to cover up any services not being provided. |
07/05/2025 | 18/05/2025 |
| 4.2 | Not all of the pharmacy's services are managed or delivered safely and effectively. The pharmacy has not kept any appropriate audit trails to verify processes for the delivery service and medicines are consistently left unattended without obtaining appropriate permission beforehand. Whilst staff are aware of the risks associated with this practice, no details have been checked to ensure the safety of this situation and no suitable notes have been maintained to help verify. This compromises the safety and supply of medicines to people. |
New delivery folder with records have already been implemented and new process initiated regarding any deliveries that have additional instructions of delivery which is documented on the patients PMR. |
07/05/2025 | 18/05/2025 |
Pharmacy inspections
Inspection reports and learning from inspections