| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have written procedures to cover all services the pharmacy offers. This includes for popular services such as, the NHS Pharmacy First service. And it cannot demonstrate all team members have read them. Team members do not always follow the written procedures for the tasks they perform and this creates risk. This includes supplying medicines privately under patient group directions (PGDs), maintaining an audit trail on dispensing labels and recording actions taken following a deviation in temperature readings of pharmacy fridges. This means team members may not be working in the most consistent and safest way. |
A pharmacy first standard operating procedure (SOP) has since been created. We have now decided to implement an SOP system where the Superintendent Pharmacist (SI) can remotely log in and see who has signed certain SOPs and who has not. This will enable us to remotely log in and check and then prompt staff members who have perhaps read through the SOP but perhaps forgotten to sign electronically. |
26/11/2025 | 24/11/2025 |
| 1.6 | The pharmacy does not always maintain accurate records as required by law. It does not record all supplies of medication made privately through patient group directions (PGDs) and these supplies are not always recorded in the patient medication record. |
We have since stopped private patient group directions (PGDs) and are not doing any more until we have a system in place for easily recording patient supplies. We are still deciding on the best way for recording these. |
26/11/2025 | 24/11/2025 |
| 4.4 | The pharmacy does not have a robust process for managing medicine recalls and safety alerts. There is no defined process to receive them, or an audit trail to show the action team members take. So, there is a risk not all medicines are safe to supply. |
We have signed up to the Medicines and Healthcare products Regulatory Agency (MHRA) medicines recalls where we will be notified via email of any medicine recalls in branch. |
26/11/2025 | 24/11/2025 |
| 4.3 | The pharmacy does not manage all of its medicines as it should, including effectively checking and making records of medicines' expiry dates. And ensuring medicines it stores out with the original packaging are labelled appropriately. |
A date checking matrix has been created and this has been sent to the branch and will be implemented to enable certain sections of the pharmacy to be checked to make sure we are date checking more often. |
26/11/2025 | 24/11/2025 |
Pharmacy inspections
Inspection reports and learning from inspections