| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 4.2 | The pharmacy cannot demonstrate that it gets all the required information to make sure that the higher-risk medicines it supplies to people are clinically appropriate. It cannot show its processes are sufficiently robust at ensuring appropriate clinical checks are undertaken with each supply. The pharmacy doesn't confirm face-to-face consultations are carried out by prescribers for botulinum toxins, even though prescribers and people's addresses are geographically widespread. And the pharmacy cannot show how prescribers have independently verified a person's weight and BMI when prescribing weight loss medication. The pharmacy supplies a high number of weight loss medicines by stock order rather than by named patient prescriptions. So the pharmacy cannot make appropriate checks on who is receiving these medicines and how they are being monitored. |
• Introduce a mandatory Higher-Risk Prescription Clinical Verification Form to ensure sufficient clinical information, consultation evidence and monitoring are confirmed before supply. • For botulinum toxin, require documented confirmation of an appropriate face-to-face/in-person consultation and physical assessment. Any concerns regarding the validity of the consultation will be clarified directly with the prescriber before supply. • For weight-management medicines, require evidence that weight/height/BMI has been independently verified and complete a patient-specific clinical assessment covering previous supplies, dose progression, contraindications and ongoing monitoring. patients cannot be identified and clinically assessed. Supplies for individual treatment will be made against appropriate named-patient prescriptions. • Where required information is missing or cannot be verified, the prescription will be placed on hold and no supply made until the pharmacist is satisfied that it is clinically appropriate. • Cease weight-management stock-order supplies where individual patients cannot be identified and clinically assessed. Supplies for individual treatment will be made against appropriate named-patient prescriptions. • Where required information is missing or cannot be verified, the prescription will be placed on hold and no supply made until the pharmacist is satisfied that it is clinically appropriate. |
11/09/2026 | |
| 4.3 | The pharmacy has not validated its cold chain supply or packaging materials. So it cannot show that temperature-sensitive medications are transported appropriately and reach people safely. |
A formal cold-chain transport validation programme will be completed for all temperature-sensitive medicines dispatched by the pharmacy. |
11/09/2026 | |
| 2.2 | The pharmacy has not enrolled some of its team members of an accredited training program. So they cannot provide assurance that they understand their role and responsibilities and are undertaking their tasks safely and effectively. |
A complete review of every pharmacy team member's role, duties, qualifications, training and competency will be undertaken. All support staff undertaking activities for which recognised training is required will be enrolled without delay onto an appropriate GPhC-approved/recognised accredited support-staff training programme. |
11/09/2026 | |
| 1.1 | The pharmacy has not fully considered and managed all the risks associated with supplying higher-risk medicines. It has not have appropriate risk assessments to manage risks associated with supplying unlicensed treatments for weight management. It does not make robust clinical checks to ensure that appropriate consultations have been undertaken for the supplies of higher-risk medicines such as botulinum toxins and weight management medications. |
A comprehensive review of all higher-risk medicines and services supplied by the pharmacy will be undertaken by the Superintendent Pharmacist. Individual documented risk assessments will be completed for each higher-risk service and medicine category, with specific risk assessments covering: • weight-management medicines; • unlicensed and off-label medicines used for weight management; • botulinum toxin and other non-surgical cosmetic medicinal products; • third-party prescribing services; • remote prescribing and consultation methods; • clinical verification and patient identification; • over-ordering, duplicate supply, diversion and unusually high prescribing/supply volumes; • follow-up and ongoing clinical monitoring. Each risk assessment will identify the potential patient-safety risks, the controls required to mitigate those risks, the person responsible for each control and the frequency with which the risk assessment will be reviewed. The risk assessments will be reviewed at least annually and sooner following an incident, change in service, change in guidance, significant increase in activity or identification of a new risk. |
11/09/2026 | |
| 1.2 | The pharmacy has not carried out any audits of its prescribing practice and of the third-party prescribers it works with. This includes completing clinical audits of supplies and monitoring third-party prescribers to show they are eligible and safe to prescribe. The pharmacy does not have adequate systems in place to identify trends that would prompt effective interventions. So, the pharmacy is unable to show how it continually monitors and improves the safety and quality of its services. |
A formal Clinical Governance and Prescribing Audit Programme will be introduced covering both prescribing undertaken within the pharmacy's own service and prescribing received from third-party prescribers. A full due-diligence file will be maintained for every prescriber and third-party prescribing organisation. This will include verification of professional registration, prescribing qualification, scope of practice, relevant clinical competence/CPD, indemnity arrangements and any relevant healthcare-provider registration. Checks will be documented on onboarding and repeated at defined intervals. Clinical audits will assess, where relevant: • patient identification; • adequacy and method of consultation; • independent verification of clinical information; • weight/height/BMI verification; • medical history and contraindication checks; • prescribing indication; • dose and quantity; • repeat and early supplies; • clinical monitoring/follow-up; • communication with the patient's usual healthcare provider where appropriate; • prescribing of unlicensed/off-label medicines; • botulinum toxin consultation requirements; • interventions, rejected prescriptions and reasons; • compliance with pharmacy SOPs and national guidance. A prescribing and supply monitoring dashboard/register will be introduced to identify trends by prescriber, medicine, strength, quantity and frequency of supply. Unusual increases, repeated supplies, unusually high volumes, geographical anomalies, duplicate requests, early requests and repeated interventions will trigger documented review by the Superintendent Pharmacist. |
11/09/2026 | |
| 1.1 | The pharmacy does not have a business continuity plan to ensure it can continue to operate safely in the event of an unexpected disruption. |
A formal Business Continuity and Disaster Recovery Plan will be implemented for the registered pharmacy. The plan will cover foreseeable disruptions including: • loss of electricity; • refrigerator or temperature-control failure; • PMR, prescribing platform, website or internet failure; • telephone/email failure; • cyber incident or loss of access to electronic records; • courier or delivery-service failure; • significant staffing shortages; • absence of the Responsible Pharmacist or Superintendent Pharmacist; • inability to access the registered premises; • fire, flood, security incident or other premises failure; • medicines shortages; • interruption to third-party prescribing services. For each scenario the plan will set out immediate patient-safety actions, escalation arrangements, responsible persons, emergency contacts, backup arrangements and the criteria for suspending pharmacy services where they cannot be provided safely. The plan will include arrangements for communicating disruption or delays to patients and prescribers; maintaining secure access to essential records and backups; quarantining medicines affected by temperature excursions; and referring or transferring patients to another appropriate registered pharmacy or healthcare provider where necessary. |
11/09/2026 | |
| 3.1 | The pharmacy displays promotional content on its website for healthcare services it does not currently offer. This could be misleading for people visiting that pharmacy's online platform. |
We will separate Halo Health Pharmacy and Halo Health Clinic into two separate websites to avoid confusion over pharmacy services and clinic services as these are two separate legal entities. An immediate review of the pharmacy website and all associated online promotional material will be undertaken. Any page, banner, treatment listing, promotional statement or booking link relating to a service which is not currently provided by the registered pharmacy will be removed or unpublished. A master list of services currently provided will be maintained and reconciled against the website. A documented website compliance review will initially be completed monthly and subsequently at a frequency determined by risk. A Website and Digital Content Governance SOP will be introduced. No new healthcare service or promotional content will be published until it has been reviewed and approved by the Superintendent Pharmacist or an appropriately delegated pharmacist. A master list of services currently provided will be maintained and reconciled against the website. A documented website compliance review will initially be completed monthly and subsequently at a frequency determined by risk. |
11/09/2026 |
Pharmacy inspections
Inspection reports and learning from inspections