| 1.6 |
Although the pharmacy goes through health questionnaires during the consultations provided for the weight loss and travel clinic, it does not keep a record of this. So, the pharmacy cannot demonstrate that it has asked the appropriate questions prior to making a supply. In addition, it does not always record the correct prescriber’s details for the private prescriptions it dispenses. And its responsible pharmacist record does not always have the time the responsible pharmacist signed out. |
1. A formal SOP has been implemented setting out clear requirements for the completion and retention of consultation and clinical records for all private services, including weight management and travel services. The SOP defines the minimum information that must be recorded to demonstrate appropriate clinical assessment and decision-making.
2. Completion and retention of consultation records, consent documentation, and clinical assessments is mandatory prior to any supply or administration under PGDs or private services. Records must be retained even where a decision is made not to proceed with supply.
3. Private and veterinary prescriptions are recorded in the designated Private and Veterinary Prescriptions Register within the pharmacy system, ensuring all legally required prescriber, patient, and supply details are captured and available for inspection.
4. All pharmacists, including locums, have been briefed and retrained on record-keeping expectations and their responsibilities under the implemented SOP, regardless of experience or length of service.
5. Ongoing oversight of record-keeping compliance is maintained through Responsible Pharmacist checks during each shift, with periodic review and governance oversight by the Superintendent Pharmacist.
6. These controls apply to all pharmacists and relevant staff without exception.
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20/01/2026 |
21/01/2026 |
| 1.1 |
The pharmacy had Standard Operating Procedures (SOPs) but these are not always easily accessible to staff. The SOPs were not available during the inspection. The pharmacy provided SOPs after the inspection, but these were not tailored to the specific pharmacy. |
1. The pharmacy’s SOPs are centrally managed through the Alphega SOP Manager, which provides full document control, including version control, reviewed and authorised dates, and defined review dates, under superintendent oversight.
2. On-site access to the Alphega SOP Manager has been implemented via a designated pharmacy workstation, ensuring SOPs are readily accessible to all staff at all times during opening hours.
3. All SOPs accessible through the system are confirmed to be current, site-specific to Pyramid Pharmacy, Barkingside, and authorised in line with governance requirements.
4. All pharmacy staff, including pharmacists and support staff, have been trained on how to access SOPs via the Alphega SOP Manager and their responsibility to work in accordance with them.
5. SOP assignment and acknowledgement is monitored through the system, with oversight of completion status at superintendent level.
6. SOP access and compliance will be monitored on an ongoing basis, with formal review at 2 years or sooner if services or regulatory requirements change.
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20/01/2026 |
21/01/2026 |
