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Pharmacy inspections

Inspection reports and learning from inspections

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Western Elms Pharmacy (1028990)

Inspection outcome: Standards not all met

Last inspection: 03/08/2021

Improvement action plan


Pharmacy context

​This is a community pharmacy on a busy main road in a multicultural area of Reading, Berkshire. The pharmacy dispenses NHS and private prescriptions, sells a range of over-the-counter medicines, and provides health advice. It also offers the New Medicine Service (NMS), local deliveries and a pharmacy-led COVID-19 vaccination service. The inspection took place during the COVID-19 pandemic. It was carried out jointly with NHS England in response to some concerns about the vaccination service.

Inspection summary findings

Principle 1. Governance

Standards not all met

​The pharmacy doesn't effectively manage all the risks associated with its services. This includes the risks from COVID-19. The pharmacy has instructions to help with this. But it cannot show that its staff have read them. This could mean that they are unclear on the pharmacy’s current processes. The pharmacy does not adequately protect people's private information. And, it has not been able to show that it is maintaining all of its records, in accordance with the law or best practice. Members of the pharmacy team generally deal with their mistakes responsibly. But they are not always recording all the necessary details. This could mean that they may be missing opportunities to spot patterns and prevent similar mistakes happening in future.

Principle 2. Staff

Standards not all met

​The pharmacy does not have a culture of openness, honesty, or learning. There appears to be a culture of fear where members of the pharmacy team are unable to openly discuss or raise concerns about the company or the pharmacy’s internal workings. This could mean that issues are not being dealt with appropriately. And, the pharmacy team is not provided with any resources to keep their skills and knowledge up to date. But the pharmacy has enough staff to manage its usual workload safely. And the team is appropriately trained.

Principle 3. Premises

Standards not all met

​The pharmacy's premises are inadequate for delivering the level of healthcare services it provides. The pharmacy has introduced some measures to help reduce the spread of COVID-19 inside its premises. But the pharmacy does not have a satisfactory cleaning rota. This has left the pharmacy cluttered and dirty. And it is not good enough for people using its services. The pharmacy is also leaving unlocked boxes containing used sharps in the retail space, putting people at risk of a needle stick injury.

Principle 4. Services, including medicines management

Standards not all met

The pharmacy does not always provide its services safely. It cannot fully demonstrate that it has been taking the appropriate action in response to safety alerts. This risks people receiving medicines and devices that are not safe to use. And the pharmacy’s team members are not making any checks to help people with higher-risk medicines take their medicines safely. But the pharmacy obtains its medicines from reputable sources.

Principle 5. Equipment and facilities

Standards met

​The pharmacy has the appropriate equipment it needs to provide its services safely. And it only just keeps its equipment clean enough.

Pharmacy details

351-353 Oxford 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.