Inspection Report
Principle 1: Governance Arrangements
Standard
Risk Management
1.1 How are the
What services are being provided?
risks
How do you ensure quality and safety of
associated
these services?
with providing
pharmacy
services are
identified and
managed?
What risk management measures would you
take if you were to provide a new service?
Do you have a regular review of adverse
incidents?
How do you report patient safety incidents?
Examples of how to achieve
Have documents ready to show
e.g. PGD documents, NHS SLAs
Training documents & certificates
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Risk assessments
Have you initiated a new service?
Facilities, equipment, staff, training,
workload, etc
Identify trends
Review procedures
Inform staff/recruitment of new staff
Improvements to the design of the
dispensary and/or service delivery, etc
Do you have an incident report book/log?
How are incidents reported
Do you have Standard Operating Procedures
in place? Can I view them?
Read a SOP & ask a member of staff what it
is they do & see if the two match up
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Have you had any dispensing incidents or
near misses?
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Do you keep a log?
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Are these being followed?
All staff working in line with SOPs
Do all staff know where SOPs are kept
Are staff named in the SOPs
Are SOPs in date & regularly reviewed
(every 2 yrs or following an incident)
Is a log kept
Are all errors logged? Including near
misses & dispensing errors
Reporting to the NPSA
Comments
Inspection Report
What would you do in the event of a
dispensing error going out to a patient?
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Is the near miss log regularly reviews?
Is there a basket system in place?
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Is there a clear workflow/checking area?
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How do you maintain hygiene within the
pharmacy?
Do you have a cleaning rota?
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How do you dispose of medicines/sharps?
Evidence of records/reporting
Root cause analysis conducted?
Examples: what did you do, how did you
improve, how do you prevent it from
happening again, what procedures have
been put in place as a result of a review.
E.g. moved similar sounding drugs, put
markers on, work flow, dispensary
benches, sufficient staffing
Makes notes on the near miss log to
show what changes you have made as a
result of reviews
Is there an infection control procedure in
place
Cleaning rota
Sharps disposed of appropriately
DOOP bins used & regularly collected
How often are your DOOP bins collected?
Can I see where you store unwanted
medicines/patient returns?
Look at how medicines are stored
What are your date checking procedures?
Are opened bottles of oral liquids marked
with date of opening?
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Where is your CD cabinet?
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Where are fridge lines stored, explain the
process of handling fridge lines?
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Is there a date checking matrix
How does the pharmacy identify short
dated stock? – do they mark packs
When is stock with short expiry dates
removed from shelves?
How are CD’s stored? CD keys? In line
with legal requirements?
Is handling of fridge lines in line with SOP
Unlicensed medicines should be
Inspection Report
How do you handle hazardous substances?
Do you have any unlicensed medicines?
Have you got a procedure in place in case
there is a potential failure or disruption to
services?
segregated from other medicines
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1.2 Is the safety &
1.4 quality of
pharmacy
services
reviewed and
monitored?
Are feedback/
concerns about
pharmacy
services or
staff can be
raised by
individuals/
organisations
and action
taken to
Complaints & feedback
How are complaints handled in the
pharmacy?
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How are they acted upon?
Is the complaints procedure advertised and
proactively publicised?
Ask a member of staff – do they know how a
patient can make a complaint?
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Are patients asked for feedback on a regular
basis?
Has this lead to positive outcomes for
patients?
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Contingency plan
What are the arrangements of business
continuity?
Have these arrangements been tested?
Alternative or replacement equipment
and facilities are accessible/available
There is sufficient capacity and
skills/expertise to cope with both
planning and unplanned staff
absences/sickness
There are alternative arrangements
should the pharmacy premises cease to
be fit for purpose
Complaints procedure in place
Record of complaints
Complaints dealt with in a timely manner
Complaints procedure should be outlined
in the practice leaflet
All staff need to be aware of the
complaints procedure
Patient survey conducted annually –
these results should be published &
feedback taken onboard
Staff need to have examples at hand of
feedback they have given to
management & changes which have
been implemented as a result
Staff meetings & outcomes if you have
any
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remedy them
Is feedback shared within and outside the
pharmacy?
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Is staff feedback taken onboard?
Patients can provide feedback on the
pharmacies NHS Choices profile
Analysis of complaints made to identify
trends & detect improvements to be
made – conduct annually
Ask a member of staff – example of when
you have suggested something which was
implemented?
1.3 Do staff have
clearly defined
roles and clear
lines of
accountability?
Do you feel comfortable giving feedback to
management & suggesting changes?
Is there an appropriate skill mix in the
pharmacy?
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Are staff roles reviewed on a regular basis?
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Are staff roles changed to meet the needs of
services or emerging needs of patients? Give
examples?
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Do staff have development plans in place?
Where tasks are delegated to other
members of the pharmacy team, what risk
management procedures are in place?
Are there clear lines of accountability and
roles?
Responsible Pharmacist Regulations
Are all procedures being following?
Pharmacy log – is the pharmacist signing in
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What training is provided to staff
What staff roles are there in the
pharmacy
Job descriptions – are these evaluated &
developed
Do staff clearly understand their job role
& do not operate outside of their
competencies
Risk manage staff operating outside of
their role – are they competent to carry
out this role?
Dispensing process – are the dispensed
and checked boxes signed on dispensing
labels to be able to have an audit trail
Are staff contracts in place?
Are staff following SOPs
Log to be kept for 5 years
Sign in and out at the beginning and end
of the day
Record absences – good practice to
Inspection Report
and out everyday, are absences recorded?
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record reason (max 2 hours)
RP SOPs to be kept for 15 years
Do you have indemnity insurance in place?
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Certificate in date
Are all legally required records kept?
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Specials
Service records e.g. PGDs, SLAs
POM register – Private rx, Emergency
supplies
Extemp dispensing
Responsible pharmacist record
CD register
Destruction of patient returned Schedule
2 CDs
Others: date checking, cleaning, fridge
temp, calibration, recalls, alerts
Is the responsible pharmacist notice
displayed?
Responsible pharmacist SOPs – are they in
place?
Ask a member of staff – what would are the
procedures to follow if the responsible
pharmacist is absent from the pharmacy?
1.5 Are indemnity/
insurance
arrangements
in place
1.6 Is record
keeping
relating to the
safe provision
of pharmacy
services in
place?
1.7 How is
information
managed to
protect the
privacy, dignity
Can I see your records for specials products?
What other record keeping documents are in 
place?
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How is your PMR backed up?
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Ensure records are clear, legible, accurate,
up to date and available at the registered
pharmacy
What security arrangements do you have in
place?
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How is confidentially maintained?
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IG regularly audited & updated
Storage & accessibly of computers &
laptops
Protecting patient sensitivity information
Public should not be able to access
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&
confidentiality
of patients/
public
Have staff been trained on information
governance?
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Are there passwords on computers? Who
has access? Are passwords regularly changed
on the PMR system?
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Are smartcards stored securely?
prescription medicines
Shop security – alarm, etc
Procedures must be in place to ensure
patient identifiable information is not
shared intentionally or unintentionally
Any confidential information stored in
area where public have access e.g.
consultation room – if so is the
room/cupboard kept locked?
Confidential waste?
Can I see your practice leaflet? – look for
data protection compliance publication
1.8 How are
children &
vulnerable
adults
safeguarded?
Does confidentially data ever leave the
pharmacy? If so how is it managed?
Procedures in place for this?
What procedures do you have in place for
safeguarding of children & vulnerable
adults?
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Are systems in place to ensure safeguarding?
Who would you report to if you have a
concern? What is the reporting procedure?
Do you give consideration to children &
vulnerable adults when services are
developed?
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SOP in place
Staff need to know when, where and
who to report concerns to
Children & vulnerable adults are to be
treated with respect & information is
provided to them in such a way that it is
understood
Consider these groups when developing
services
Groups treated with respect and made to
feel safe
See PharmaPlus procedures for further
information & examples
Inspection Report
Principle 2: Empowered & Competent Staff
2.1 Are sufficient
How many staff are present in the
staff available
pharmacy?
to provide
pharmacy
Do they have an appropriate skill mix to
services safely, provide pharmacy services safely?
with
appropriate
Are staff suitably trained?
skills and
qualifications?
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2.2 Do staff have
the
appropriate
skills,
qualifications
and
competence
for their role/
task or, if in
training are
they working
under the
supervision of
another person
Does learning and development take place
for all staff?
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Is there an induction procedure for staff?
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Is there an appraisal system?
Do staff reflect on their own performance
and identify learning and development
needs? And are they supported to address
them?
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Does the pharmacy encourage, support and
provide access to CPD/continuous education
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Continuous learning taking place
Staff have appropriate skills to reflect
services being provided
In order to qualify for a Practice
Payment, the NHS Pharmacy Contract
requires contractors to have minimum
numbers of dispensary staff in place
linked to the number of items dispensed
Staff certificates available? Using GPhC
approved programmes or approved
sources e.g. CPPE
Evidence of staff currently undergoing
training
Development plans in place
Keep training matrix for every member of
the pharmacy team
Staff performance should be regularly
reviewed
Signed staff contracts in place &
induction pack including a locum
agreement & locum guide
Staff have appropriate registration &
evidence of training/competence for
carrying out services (e.g. MURs,
substance misuse) – these should be
reviewed regularly
Evidence of appraisals & learning
development & personal development
plans
Staff know their roles
Competency of staff is reviewed regularly
Inspection Report
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2.3 Compliance
with
professionals/
legal
obligations and
empowerment
to exercise
professional
judgement in
interests of
patients/
public
Are pharmacy professionals and staff
supported and empowered to make
decisions and act proactively for the benefits
of their patients and the public and other
members of staff?
Is there a sale of medicines protocol in place
which staff follow
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2.4 Is there a
culture of
openness,
honesty and
learning
Does the pharmacy ensure that the
pharmacy team learns and improves?
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Are staff fully involved in improving delivery
of pharmacy services?
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Do staff understand their own and other
HCP’s legal and professional obligations
when providing pharmacy services?
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Near miss/incident logs – can provide
learning for staff
Staff can describe their suggestions for
improvements to pharmacy services as a
result of training and development
E.g. OTC product training sessions leading
to increased knowledge to advise
patients/ refer
Decision making should be proactive and
professional
Pharmacy procedures should be
understood by staff and followed
Senior members of staff with
management responsibilities are able to
professionally and legally fulfil their
duties with the correct authority
Do staff have appropriate reference
sources available to them in the
pharmacy? E.g. BNF, counter assistants
reference sources, DT, etc
Are mistakes learnt from
Shared learning from mistakes – open
discussions – is there evidence of this
Errors, incidents and near misses are
regularly reviewed and work systems &
processes modified accordingly to reduce
the recurrence of similar incidents
Are patient safety incidents reported to
the NPSA and a log kept in the pharmacy
Staff to accept responsibility for their
mistakes and are involved in action taken
to prevent similar occurances
Inspection Report
2.5 Are staff
empowered to
provide
feedback and
raise concern
about meeting
these
standards and
other aspects
of pharmacy
services
2.6 Are incentives
being offered
which may
compromise
patients or the
publics health,
safety or
wellbeing and
professional
judgement
Do staff feel empowered to suggest changes
or provide feedback to senior members and
raise concerns?
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Do staff know about the whistleblowing
policy?
Staff to be encouraged to raise concerns
where actions of others or procedures in
the pharmacy may put others at risk
Staff are confident in using the
whistleblowing policy and are
encouraged to do so
Are staff opinions and feedback regularly
sought in order to reduce risk and make
improvements to patient/public services
What targets and incentives does the
pharmacy have in place/provide staff
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Check targets/incentives are appropriate
and staff are not expected to act other
than within their professional judgement
and the interests of the patient
Demonstrate patients are not at risk due
to incentives or targets
Inspection Report
Principle 3: Managing pharmacy premises
3.1 Is the premises Is the building safe and well maintained?
safe, clean and
properly
Is repair work/maintenance carried out
maintained
safely and in a timely manner?
and suitable
for the
Are patients given advance notice of planned
pharmacy
maintenance work and provided with
services
appropriate information?
provided?
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Designs & layout of the premises:
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Sufficient size for the services offered?
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Is there a consultation room – built to
correct specifications to enable provision of
pharmacy services?
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Equality Act – how does the pharmacy
premises support patients with disabilities
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Does patient and public feedback inform the
design and layout of the public area of the
pharmacy?
Is there a health & safety policy in place? Is
health and safety law being followed?
Fire safety?
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Appropriate lighting, heating, plumbing,
alarm system – regularly tested?
Signposting, how will services be
affected, how long these services will be
affected for
Professional looking pharmacy premises
Clean, tidy, well organised
All pharmacy fixtures & fittings are well
maintained and kept in good order
Business continuity plans are in place
with contact details of local contractors
e.g. plumbers & electricians
Sufficient dispensary space for checking
prescriptions or preparation of
monitored dosage systems
Dispensing workflow – should not be
obstructed by cramped conditions,
particularly when the pharmacy is fully
staffed during busy periods
E.g. provision of ramps, hearing loops,
aisles/doorways wide enough for
wheelchairs/pushchairs
Sufficient and appropriate space should
be available to store stock awaiting
collection or delivery, particularly large
bulky items
Sufficient storage available for stock
Stock should not be stored on the floor
e.g. where there is risk of unauthorised
access
Stock should not be stored in area that
Inspection Report
3.2 Does the
design of the
premises
protect the
privacy, dignity
and
confidentiality
of patients
3.3 Is there an
appropriate
level of
hygiene
maintained,
depending on
services
offered?
Consultation room available?
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Is it clearly signposted & promoted by staff
during conversation with patients?
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Look out for use of the consultation room
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Is the pharmacy clean, tidy and well
organised?
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How often is the pharmacy cleaned?
Are floor spaces kept clear?
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Ceilings and walls well maintained?
Clean sink
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3.4 Are the
What security features are present in your
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may be subject to temperature variations
e.g. top shelves or next to a refrigerator
May be other quiet areas in the
pharmacy away from the main pharmacy
counter where patients can discuss their
medicines
Layout of the pharmacy allows patient
confidentiality and privacy to be
protected
Staff and patients are able to have
confidential conversations
IG SOPs are in place
Staff have signed confidentiality clauses
Infection control procedures in place
Cleaning rota
Cleaning equipment readily available and
used and appropriate signage is in place
(e.g. reminding staff to wash hands)
Regular removal of waste – waste
containers are filled to the appropriate
fill line
Contact details of waste contractors/pest
control are available
All areas of the pharmacy need to be
clean/hygienic – stock room, kitchen,
toilet, etc
Adequate sink/hand basins with hot and
cold water supplies are provided in
appropriate areas to allow hygienic
preparation of medicines,
cleaning/sanitation and hand washing
Locks/alarms/shutters/CCTV
Inspection Report
premises
secure and
safeguarded
from
unauthorised
access?
premises?
How often are these security features
reviewed?
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Is excess stock kept in a secure area? Access
from the back of the pharmacy?
Who holds keys to the pharmacy?
Controlled Drugs:
How are the CD keys stored – during the day
& overnight?
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What is your procedure for destruction of
CD’s? Records? T28 exemption?
Is your CD register up to date?
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Balances well maintained? Balance checks
occurring?
Windows/hatches – locked
Working alarm systems – cover all areas
of the pharmacy
Emergency call out procedure is in place
Evidence of reviews following a breach in
security and action taken
Follow all controlled drug regulations
CD keys to be kept on the pharmacist
during the day
At night should be stored securely – e.g.
in a bag, stapled, signed & dated by the
pharmacist & stored securely
CD destruction kits should be available
Balance checks should be occurring in
line with SOPs
Check CD cupboard – bagged prescriptions,
out of date medicines, CD storage, solely
used for CDs
Is the CD cupboard bolted to the wall?
Do you have the details of your accountable
officer?
3.5 Are pharmacy
How are CDs delivered to patients – what is
your procedure?
Working Area:
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Ambient room temperature is
Inspection Report
services
provided in an
environment
that is
appropriate for
the provision
of healthcare?
Is there sufficient lighting and ventilation?
How do you maintain the temperature in the
pharmacy?
What happens if the pharmacy temperature
increases above 25C?
Are there any distractions in the pharmacy
e.g. audio/video equipment?
Professional area:
Is there a clearly defined professional area?
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Are medicines in this area healthcare
related? E.g. alcohol and tobacco is not sold
External Areas:
What posters/campaigns are running?
Are they relevant? Kept up to date?
What is displayed in the shop, windows,
doors? Does it create a professional
appearance?
Shop front signage needs to be
professionally displayed
Are pharmacy opening hours displayed?
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maintained at a level to ensure medicines
remain fit for purpose and services can
be provided comfortably
Temperature control: AC unit, fans,
windows – monitor using thermometers
Volume levels of audio/video equipment
being used in the pharmacy should be
appropriate and not form a distraction to
offering pharmacy services
Confectionary not to be kept near the
pharmacy counter
Appearance of the premises presents a
professional image for the provision
pharmacy services
Inspectors will examine all material –
ensure you have relevant campaigns
running
Windows are not cluttered – keep it
professional
Inspection Report
Principle 4: Delivering Pharmacy Services
4.1 Are the
How are your services advertised?
pharmacy
services
How do you choose what services you
provided
provide?
accessible to
patients and
Do you provide services to fit the health
the public
needs of the local community?
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If your pharmacy is in an area where there is
a large community who do not speak English
how do you provide services to these
patients?
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What facilities do you provide for disable
patients?
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Is seating available for patients?
Signposting – does this occur when you are
unable to provide a pharmacy service?
4.2 How are
pharmacy
services
managed and
delivered
safely and
effectively?
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TELL THE INSPECTOR ABOUT ALL YOUR
SERVICES!!!!
Pharmacy services available are clearly
displayed, up to date and actively
promoted
Practice leaflet – accurate & on display
Services should be provided to fit the
needs of your local community – have
examples ready
Bilingual leaflets
Multilingual staff
Staff should be clearly identifiable – e.g.
uniforms & staff badges to indicate name
& job title/role
Seating should be available to assist
those who may find it difficult to stand
Clear lines of accountability – who is
responsible for what?
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SOP on signposting in place
Patients are referred/signposted to other
appropriate health and social care
providers or support organisations, when
the pharmacy cannot meet their needs
Make SOPs available for services
Are staff following SOPs
Local PGD protocols being followed
Audit trails
Use of baskets in the dispensing process
Monitored dosage systems:
Are PILs being put in patients bags?
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Ensure all points are fulfilled
Ensure staff have relevant qualifications
Are staff aware of when, where and who to
signpost to?
Do you have SOPs in place for all services
provided?
Inspection Report
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Staff to ensure hygiene when preparing
MDS
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E.g. anticoagulants, opioids, oral
methotrexate, insulin
SOPs in place for dispensing these
medicines?
Are tablet shape/colour/markings/ etc
recorded on the MDS
Are warning labels put on the MDS (label
requirements)
Who has dispensed & checked the MDS –
marked on MDS?
Ensure preparation of MDS fulfil hygiene
requirements
Qualified member of staff to prepare MDS to
patients?
High Risk medicines:
How do you identify patients taking high risk
medicines?
Are these patients proactively targeted &
suitably counselled?
Are patients with conditions such as
diabetes, CHD, high BP, smokers &
overweight patients proactively targeted for
health promotion and healthy lifestyle
advice?
Evidence of health promotion in the
pharmacy
Stock Management:
Is stock which is safe and appropriate to sell
clearly segregated from that which is not?
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This could be done when handing out
medicines, by counter staff, during
MURs, NMS, etc
Should participate in public health
campaigns & local campaigns
SOP – Safe storage of medicines
Stock rotation system
Managing expiry dates e.g. marking
boxes
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Stock rotation system is in place?
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How are out of date medicines handled? Or
those nearing their expiry date?
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Are oral liquids marked with date of
opening/ expiry dates?
Date checking matrix
Ensure procedures are in place to keep
owing items to a minimum & manage
long term out of stock medicines
Patients informed if medicine is short
dated & provided with medicines with a
sufficient shelf life
How are owings managed – in line with SOP?
What procedures are in place to manage
long term out of stock products?
Deliveries:
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How are your deliveries made?
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Do you have a record book?
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Record book to be kept & all deliveries to
be logged
Controlled drug procedures to be
followed
Cold chain maintained
Do you deliver controlled drugs? What are
your procedures?
How do you maintain the cold chain of
products?
Are audits conducted annually
4.3 Medicines &
medical
devices
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How do you ensure you only obtain products
from a reputable source?
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Contract monitoring requirement – one
NHS England lead & one practice based
audit to be undertaken
Perform background checks
Only use reputable wholesalers
Check WDLs
Maintain audit trails
How do you file/store your invoices?
Are your medicines safe and fit for purpose?
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Ensure stock is not stored in a location
How are your medicines sourced?
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How are your medicines stored?
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How do you ensure ambient temperature is
maintained? Do you monitor the
temperature? What would you do if the
temperature fell outside its range?
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How do you ensure correct storage of fridge
lines?
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Do you ensure daily monitoring of fridge
temperatures – can I see the log?
Is your thermometer calibrated in line with
manufacturers instructions?
Look in the fridge – ensure medicines are
stored appropriately – is there any food
stored in the fridge?
How are cytotoxic medicine stored and
handled? Separate counting triangles?
Are hazardous substances correctly handled
and stored?
Are medicines stored in their original
packaging? If some are not are they marked
with batch numbers and expiry dates?
Are medicines sold/supplied in appropriate
containers? – observe
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which may be affected by extremes of
temperature
Medicines are not to be stored on the
floor
Know procedures for dealing with
medicines when they are exposed to
temperatures outside of ranges
Procedures on how to deal with
temperatures when they go above 25C –
AC, fan, windows, etc
Fridge – back up fridge – how long has
the temperature been out of range –
what do you need to do with the stock
Food must not be stored in the fridge
with medicinal products
Odd tablets should not be transferred
from their original pack into another pack
Separate counting triangles for cytotoxics
Inspection Report
Are they correctly and securely stored in line
with their legal category?
Are your medicines stored securely?
Are they safeguarded from unauthorised
access?
Controlled drugs - who has access & keys?
Medicines are supplied safely and accurately
and appropriate to patients individual
needs?
Are patients given correct information on
treatment and use of medicines & medicinal
devices?
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How do you dispose of waste?
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Do you have appropriately coloured DOOP
bins?
Yellow sharps bins? Are they stored securely
& used correctly?
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Where are patient returned medicines kept?
How are they handled when received?
Are patients actively counselled to promote
the return of unwanted/unused medicines/
medical devices?
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See above with regards to controlled
drugs
Are loading areas for deliveries secure?
Are patients able to access POMs ?
Access to the dispensary and medicines is
restricted to authorised staff
Ensure staff are following sales protocols
& referring to the pharmacist when
necessary
Using WWHAM questions
Patients/carers are given information/
advice so that they can make informed
decisions when purchasing medicines
Counselling and advice is provided to
ensure effective and safe use of
medicines, devices & pharmacy services
Staff asking patients about returned
medicines before accepting them e.g. are
there sharps contained in these returns,
CDs, etc
IG SOPs in place
T28 exemption for destruction of CDs to
be in place
Battery recycling facility is available if
more than 32kg of portable batteries are
sold per year – promotion to public
where appropriate
How often is waste collected – ensure a
suitable collection time
Inspection Report
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Consignment notes are to be kept for 3
years
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Quarantine
Relevant authorities notified
Raise concerns with other pharmacies/
prescribers/ manufacturers
Pharmacy should proactively follow up
patients who have received a product not
fit for purpose
Yellow card reporting scheme
Legal requirements for CDs followed?
Is confidentiality of patient returned
medicines/ devices protected?
Is patient returned medicines and out of
date stock segregated from normal
pharmacy stock?
4.4 Are concerns
raised when it
is suspected
that medicines
or medical
devices are not
fit for
purpose?
Disposal of waste is in line with
environmental guidance
How are defective/ counterfeit/ medical
devices dealt with?
Do you have a SOP in place for dealing with
drug alerts?

Do you have a record of drug alerts actioned
upon?

Inspection Report
Principle 5: Equipment & Facilities
5.1 Do you have
Do you have a private consultation area?
equipment and
facilities
Do you have up to date reference sources
needed to
available?
provide
pharmacy
Does the pharmacy have internet access to
services readily be able to view the most up to date
available?
resources & receive email alerts?
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Consultation area – to the specifications
BNF, Drug Tariff, Stockley’s drug
interactions, Martindale
Equipment: Dispensing baskets,
calibrated scales, glass measures (CE
marked), counting triangles, MDS
equipment, gloves, aprons, cleaning
equipment, fridge, etc
Do you have appropriate equipment to be
able to provide services?
Is seating available in the pharmacy?
Do you have facilities to accommodate
patients needs?

Support for patients with disabilities?

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5.2 Are your
equipment and
fit for
purpose?
Is your equipment obtained from a
reputable source?
What equipment do you have to provide
your services?
Is your equipment safe to use and fit for
purpose?
Does regular cleaning of equipment occur?
All equipment should be clean and hygienic


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E.g. large print labels, product labels in
different languages, print PILs in large
print
E.g. availability of induction (hearing)
loop
Equality Act – procedures and
assessments
Use recognised suppliers
Installation by a recognised company
Medical devices should have a CE mark
Measures should not be chipped – clean
and well maintained
Calibration & servicing to occur in line
with manufacturers recommendations
Measures should be cleaned between
uses
Tablet counters cleaned regularly
Methadone measures not to be used for
Inspection Report
Do you service/calibrate your equipment?
And how often does this occur?
Do you have records/certificates of
calibration?
If deficiencies are found – what corrective
action is taken?


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Is the equipment appropriately maintained?

Is seating provided? Clean & safe
Are your equipment and facilities proactively
reviewed to improve patient care? Example
5.3 Are equipment
and facilities
used in a way
that protects
the privacy &
dignity of the
patients and
the public who
receive
pharmacy
services?
Are concerns raised when not fit for
purpose?
Is equipment stored securely to prevent
unauthorised access?
Where are sharps stored?
Storage and access to smartcards? Password
protection?
Are computer passwords regularly changed?
Where are prescriptions & registers stored?
How do you prevent disclosure of
confidential information:
PMR screen positioning?
Prescription retrieval system?

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other medicines
Electrical equipment to be kept away
from sink areas
Pharmacies should share concerns with
other pharmacies/ organisations to raise
awareness of equipment deficiencies
Patient feedback taken on board to
improve facilities, equipment, services,
etc in order to improve patient care
Serviced/maintained by a reputable
company if appropriate – these details
should be made available in case of an
emergency/breakdown/ failure of
equipment
Business continuity
Sharps should not be stored where
patients can gain access to them –should
be stored safely and securely
IG SOPs
Inspection Report
Passwords?
Shredding?
Locked cabinets?
Etc?
NOTE:
To be rate POOR – a pharmacy will have to be failing significantly and be putting patient safety at risk
Want to see outcomes from procedures put in place
Need to tell the GPhC what you are doing in your pharmacy – why you are great, how are you serving the local needs of your community – don’t wait for
them to ask!
Think of examples for the questions they will be asking in advance – the more examples you have the higher your rating will be!
At the end of the inspection the inspector will go through their findings with the Responsible Pharmacist, who will be asked to sign the report to confirm
their agreement to the findings. The Responsible Pharmacist has an opportunity to make any additional comments. This is important to show that the
evidence recorded on the report is an accurate reflection of what the inspector saw / was shown on the day. The Responsible Pharmacist is not signing to
agree to an inspection judgement, which will not be made until after the inspection.
Reports:
 Superintendents will have 2 days to confirm the report is accurate
 2 days to respond to the action points
 Agreed timeframe for actions points will be set
 Action points may just require email confirmation or another inspection may take place
 The superintendent is responsible for the action plan