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Pharmacy inspections

Inspection reports and learning from inspections

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SQ Invest Ltd (9011080)

Inspection outcome: Standards not all met

Last inspection: 07/11/2019

Improvement action plan


Pharmacy context

This is a distance selling pharmacy ( linked to an online prescribing service. The pharmacy dispenses private prescriptions only, generated by two online EU based prescribers in Romania. The vast majority of people using the pharmacy are based in the UK. The types of medicines dispensed included: pain relief (codeine phosphate, dihydrocodeine, co-codamol) and sleep aids (zopiclone). The pharmacy is closed to the public and situated in a business park and medicines are delivered to people via courier.

Inspection summary findings

Principle 1. Governance

Standards not all met

The pharmacy’s working practices are not safe. The pharmacy does not manage and identify all the risks associated with the services it provides. It does not have systems in place to ensure that the safety and quality of the services it provides are regularly reviewed and monitored. For example, it does not do regular audits of how many prescriptions had been refused by the prescribers. It does not audit the number of people who submit incorrect details of their regular doctor. And it does not audit its process for receiving responses back from people’s regular doctors. This increases the risk that people with addiction problems go undetected by the pharmacy and are still supplied medicines. The pharmacy does not consistently keep and maintain records of clinical decisions. People can purchase high-risk medicines on a regular basis without the knowledge of their GP. And vulnerable people might be able to obtain medicines that could cause them harm. The pharmacy uses prescribers who are not based in the UK and it is unable to show that the prescribers are following UK guidance. This means that the pharmacy cannot show that its prescribing service is safe.

Principle 2. Staff

Standards not all met

There is evidence that the pharmacy supplies medicines without obtaining sufficient information to be able to assess whether they are safe and appropriate. For example, repeated supplies are made to people without having received confirmation of treatment from their regular GP. The pharmacy has enough team members to manage its workload. They have regular meetings and they are asked about how services can be improved. Team members are given some training but this is provided verbally and is not very structured. This could make it harder for them to keep their knowledge and skills up to date. The interest of people using the service is overlooked by prescribers only being paid when they issue a prescription and the pharmacy team are not carrying out sufficient checks that these issued prescriptions are clinically suitable for people. Prescribers are only paid when a prescription is issued, and this incentive risks compromising the health and wellbeing of people using the service. And the pharmacy is not carrying out sufficient checks that these issued prescriptions are clinically suitable for people.

Principle 3. Premises

Standards not all met

The pharmacy’s website does not give people all the information they need about the prescribers the pharmacy uses. This could make it harder for people to check who prescribes their medicines. The website allows people to select the medicine, strength and quantity prior to receiving a consultation. And this is contrary to the GPhC Guidance for registered pharmacies providing pharmacy services at a distance, including the internet. However, the website displays the required MHRA logo to help people identify that the website can legally sell medicines. The premises are clean and provides a suitable environment for the pharmacy’s services. And they are secured from unauthorised access.

Principle 4. Services, including medicines management

Standards not all met

The pharmacy does not provide its services safely. It does not make sufficient checks to ensure that all the medication it supplies are appropriate for people. And it supplies some medicines which may not be suitable for supply via remote consultations. The pharmacy supplies medicines without routinely waiting for a response from people’s regular doctor to make sure that their regular doctor agrees to the supply. This is a risk because people’s conditions might not be properly monitored, and their use of the medication may not be appropriately controlled. People’s GPs are not contacted by the prescriber in advance of issuing a prescription. And in the absence of contact from the person’s GP, prescribers are not making a clear record explaining their justification for prescribing. This means that people may receive medicines which are not suitable for them. The pharmacy does not review the safety of its prescribing and supply service effectively. There is a lack of shared care between the pharmacy team, prescriber and GP. Prescribers issue prescriptions by default without waiting to hear from the patient’s GP or without carrying out necessary checks. And this is not in-line with the GMC prescribing guidance. However, the pharmacy obtains its medicines from reputable sources and stores them properly.

Principle 5. Equipment and facilities

Standards met

The pharmacy largely has the equipment and facilities it needs for its services. It uses its equipment to help protect people’s personal information.

Pharmacy details

Unit 22
St. Olav's Court
Lower Road

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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

Met The pharmacy has met all the standards for registered pharmacies
Not all met 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.