Pharmacy context
This pharmacy provides its services at a distance and it is physically not accessible to the public. It is located within a business centre and its main business is compounding unlicensed medicines under
a s10 exemption which it prepares in its laboratory. It supplies these and
other unlicensed medicines against private prescriptions from external prescribers. The pharmacy mainly supplies hormone replacement therapy and medication for thyroid conditions. It also supplies medicines against a relatively small number of prescriptions that are generated by its in-house Pharmacist (PIP) Independent Prescriber.
Inspection summary findings
Principle 1. Governance
The pharmacy does not adequately identify and manage the risks associated with its prescribing service. Although it has done a risk assessment, this does not consider the individual medicines it prescribes, and it does not have prescribing policies for these medicines. The pharmacy cannot always sufficiently demonstrate that it relies on clinical evidence relevant to the UK when prescribing unlicensed medicines. And it does not always take account of relevant guidance, for example when prescribing antibiotics. The pharmacy does not have a robust process to monitor the safety and quality of the prescribing service, for example by doing regular clinical audits. So, it cannot sufficiently demonstrate that its prescribing is provided in line with appropriate guidance or that controls cited in its risk assessment are implemented effectively. People can provide feedback or make complaints about the pharmacy's services. And team members protect people’s personal information. The pharmacy largely keeps the records it needs to by law.
Principle 2. Staff
The pharmacy has enough team members to manage its workload. And team members do some ongoing training in the pharmacy to keep their knowledge and skills up to date. Team members feel comfortable about raising any concerns they have.
Principle 3. Premises
The pharmacy’s website gives people information about the pharmacy. The premises are clean, and they are secured from unauthorised access. It provides a suitable space for its services and the premises are well laid out to clearly separate the various departments.
Principle 4. Services, including medicines management
There are risks with the pharmacy’s prescribing service that need addressing, as described under
Principle 1, but the pharmacy generally provides its other services safely. It gets its medicine from reputable sources and stores it
appropriately. And the team has robust processes in place to check the
suitability of ingredients and compounded medicines.
Principle 5. Equipment and facilities
The pharmacy has the appropriate equipment to provide its services safely. And it protects people’s privacy when using its equipment.
What do the inspection outcomes mean?
After an inspection each pharmacy receives one overall outcome. This will be either Standards met or Standards not all met
| The pharmacy has met all the standards for registered pharmacies | |
| The pharmacy has not met one or more of the standards for registered pharmacies |
What does 'pharmacy has not met all standards' mean?
When a pharmacy has not met all standards, they are required to complete an improvement action plan, which you can find via a link at the top left of this page. We monitor progress to check the improvements are made and inspect again after six months to make sure the pharmacy is maintaining these improvements. A new report will then be published.