| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy provides an NHS prescribing service. But written procedures are not available to view, and members of the team have not been trained in the procedures or understand how the service is operated or provided. So they may not fully understand their roles and responsibilities when providing the service. |
The branch has now been provided with physical copies of prescribing standard operating procedures. This is available within branch for all staff to view and familiarise themselves with the procedures involved with the NHS IP Pathfinder programme. This will ultimately lead to the entire team having a better understanding of the process and the roles in which they are carrying out and providing. The pharmacy team have also been provided with a copy of the IP pathfinder risk log in which they can use to help staff identify the most common risks which may arise in order to minimise risk in providing the service. |
20/02/2026 | 18/02/2026 |
| 1.1 | The pharmacy provides an NHS prescribing service. But written procedures are not available to view, and members of the team have not been trained in the procedures or understand how the service is operated or provided. So they may not fully understand their roles and responsibilities when providing the service. |
The branch has now been provided with physical copies of prescribing standard operating procedures. This is available within branch for all staff to view and familiarise themselves with the procedures involved with the NHS IP Pathfinder programme. This will ultimately lead to the entire team having a better understanding of the process and the roles in which they are carrying out and providing. The pharmacy team have also been provided with a copy of the IP pathfinder risk log in which they can use to help staff identify the most common risks which may arise in order to minimise risk in providing the service. |
20/02/2026 | 18/02/2026 |
| 4.3 | The pharmacy does not store some of its higher risk medicines in suitable locations. So they are unable to demonstrate they are doing all they can to ensure these medicines are kept safe. |
The pharmacy did not previously have the cabinets used to store higher risk medicines bolted and secured to the premises. It has now been bolted and secured in place as in accordance with guidance and recommendations for the correct storage of higher risk medicines. |
20/02/2026 | 18/02/2026 |
| 4.3 | The pharmacy stores its fridge medicines in refrigerators. But members of the pharmacy team do not record the daily fridge temperature checks it undertakes. So it may not be able to show the medicines were always stored at the correct temperature in the event of a query or a concern. |
The Pharmacy has since contacted the PMR system within the branch and has had a physical pop-up reminder for fridge temperatures installed onto the computers. This reminder will appear daily and will prompt the team to record temperatures as soon as the system is turned on in the morning to ensure the cold chain was maintained overnight. The pharmacy team has been briefed on the importance of recording fridge temperatures in order to maintain adequate cold chain to reduce the risk of patient safety events. The pharmacy team has additionally reviewed and signed the standard operating procedures for the storage of fridge medicines within the pharmacy. |
20/02/2026 | 18/02/2026 |
| 4.3 | The pharmacy does not store some of its higher risk medicines in suitable locations. So they are unable to demonstrate they are doing all they can to ensure these medicines are kept safe. |
The pharmacy did not previously have the cabinets used to store higher risk medicines bolted and secured to the premises. It has now been bolted and secured in place as in accordance with guidance and recommendations for the correct storage of higher risk medicines. |
20/02/2026 | 18/02/2026 |
| 4.3 | The pharmacy stores its fridge medicines in refrigerators. But members of the pharmacy team do not record the daily fridge temperature checks it undertakes. So it may not be able to show the medicines were always stored at the correct temperature in the event of a query or a concern. |
The Pharmacy has since contacted the PMR system within the branch and has had a physical pop-up reminder for fridge temperatures installed onto the computers. This reminder will appear daily and will prompt the team to record temperatures as soon as the system is turned on in the morning to ensure the cold chain was maintained overnight. The pharmacy team has been briefed on the importance of recording fridge temperatures in order to maintain adequate cold chain to reduce the risk of patient safety events. The pharmacy team has additionally reviewed and signed the standard operating procedures for the storage of fridge medicines within the pharmacy. |
20/02/2026 | 18/02/2026 |