| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has written procedures, but it cannot demonstrate that all team members have read and understood them. And team members do not always follow the written procedures for the tasks they perform. So they may not be following safe or agreed processes. |
Staff have all been asked to read through the standard operating procedures (SOPs) again whilst Superintendent pharmacist (SI) is in the store so they are able to ask questions for anything which is unclear. SOPs will also be reviewed by the SI to ensure dates are written and that SOPs are reviewed every 2 years. |
02/07/2025 | 23/07/2025 |
| 1.6 | The pharmacy does not keep accurate records as required by law such as private prescription records and records for higer-risk medicines. |
The responsible pharmacist (RP) working in branch has been made aware that they need to look through all previous private prescriptions and ensure they are entered into the private prescription register and all future prescriptions. |
02/07/2025 | 23/07/2025 |
| 1.5 | The pharmacy cannot demonstrate that it has the appropriate insurance arrangements in place from the day it opened. Following the inspection, the pharmacy provided evidence that it has appropriate indemnity insurance but the certificate is dated after the inspection. So people using the pharmacy's service might not have been adequately covered before this date. |
The insurance had recently been changed to the new location and also to the new company. A copy of these documents will now be available on the wall for everybody to be able to view. |
18/06/2025 | 23/07/2025 |
| 2.2 | This pharmacy has not enrolled all team members on the appropriate qualification training for their role. And so, some team members are not qualified for the activities they undertake. |
Delivery driver has been enrolled onto the delivering medicines safely and effectively course |
02/07/2025 | 23/07/2025 |
| 4.2 | The pharmacy does not have a robust audit trail in place to show who was involved at each stage of the dispensing process. This is not in line with its written procedures and may make it harder to resolve any queries or problems that arise. |
All staff members have been told labels must be signed by everybody. Regardless if only one person has been dispensing all day. Dispensed by and checked by labels must be initialed always. |
02/07/2025 | 23/07/2025 |
| 4.3 | The pharmacy does not always store some it's higher-risk medicines in line with requirements. Team members do not always label stock medicines appropriately. This makes it harder for the pharmacy to ensure the medicines are suitable to supply to people. |
The surgery will be contacted again to make them aware that drugs such as Epilim Chrono are unsuitable for multi-compartment compliance pack dispensing. All staff have been spoken to regarding removing previous labels on dispensed medications to ensure no patient identifiable information is on any medication put back onto the shelf. Staff have been asked to refamiliarize themselves with what medicines must be kept under lock and key. |
02/07/2025 | 23/07/2025 |
Pharmacy inspections
Inspection reports and learning from inspections