Registered pharmacy inspection report
Pharmacy Name: Leek Pharmacy, 55 Queens Drive, LEEK,
Staffordshire, ST13 6QF
Pharmacy reference: 1116505
Type of pharmacy: Community
Date of inspection: 14/07/2022
Pharmacy context
This busy community pharmacy is located on a parade of shops in a residential area. Most people who
use the pharmacy are from the local area and a home delivery service is available. The pharmacy
dispenses NHS prescriptions, and it sells a range of over-the-counter medicines. It supplies some
medicines in multi-compartment compliance aid packs to help people take their medicines at the right
time.
Overall inspection outcome
aStandards met
Required Action: None
Follow this link to find out what the inspections possible outcomes mean
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Summary of notable practice for each principle
Principle Exception standard Notable
Principle Why
finding reference practice
Standards
1. Governance N/A N/A N/A
met
Standards
2. Staff N/A N/A N/A
met
Standards
3. Premises N/A N/A N/A
met
4. Services, including medicines Standards
N/A N/A N/A
management met
Standards
5. Equipment and facilities N/A N/A N/A
met
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Principle 1 - Governance aStandards met
Summary findings
The pharmacy generally manages risks to make sure its services are safe, and it acts to improve patient
safety. Members of the pharmacy team work to professional standards. They are clear about their roles
and responsibilities and complete the records that they need to by law. The team has written
procedures on keeping people’s private information safe. And team members understand how they can
help to protect the welfare of vulnerable people.
Inspector's evidence
The pharmacy had up-to-date standard operating procedures (SOPs) for the services provided, with
signatures showing that members of the pharmacy team had read and accepted them. Roles and
responsibilities were set out in the SOPs and the pharmacy team members were performing duties
which were in line with their roles. They were wearing uniforms and most had NHS identity (ID) smart
cards. The responsible pharmacist (RP) notice was displaying the wrong pharmacist’s name, which could
be confusing in the event of an error or problem, but this was corrected when pointed out.
The pharmacy team recorded dispensing incidents on the online national recording system and
reported them to the pharmacist superintendent (SI). Learning points were shared with the pharmacy
team and actions were taken to prevent re-occurrences. For example, following an incident when the
incorrect form of carbamazepine had been supplied, a ‘select with care’ alert sticker had been attached
to the dispensary shelf in front of the prolonged release version. There was a near miss log, but it had
not been used for a few months to record or review near miss errors, so team members might be
missing out on additional learning opportunities. Alert stickers, designed with capital letters to highlight
the differences in the names were placed in front of look-alike and sound-alike drugs (LASAs) such as
amLODipine and amiTRIPtyline, so extra care would be taken when selecting these. Clear plastic bags
were used for assembled CDs and insulin to allow an additional check at hand out.
The pharmacy had a complaint procedure and this was outlined in a SOP, but there was nothing on
display informing people how they might raise concerns or leave feedback. Insurance arrangements
were in place. A current certificate of professional indemnity insurance was on display in the pharmacy.
The RP log was generally in order, although one of the regular pharmacists did not always enter the
time they ceased their activities each day, so it did not provide a complete record. Private prescription
records and the controlled drug (CD) register were appropriately maintained. Records of CD running
balances were kept and these were regularly audited. Two CD balances were checked and found to be
correct. Patient returned CDs were recorded and disposed of appropriately.
Members of the pharmacy team had received training on information governance (IG). A new member
of the team confirmed they had read about patient confidentiality when they started working at the
pharmacy, and they understood the difference between confidential and general waste. Confidential
waste was collected in designated bags which were sealed until they were shredded on site. Assembled
prescriptions and paperwork containing patient confidential information were stored appropriately so
that people’s details could not be seen by members of the public. A statement that the pharmacy
complied with the General Data Protection Regulation (GDPR) and the NHS Code of Confidentiality was
included in the ‘safeguarding your information’ leaflets. A privacy statement was on display, in line with
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the GDPR.
The pharmacist had completed training on safeguarding. A member of the pharmacy team confirmed
they would voice any concerns regarding children and vulnerable adults to the pharmacist working at
the time. The pharmacy had a chaperone policy, and this was highlighted to people. Some members of
the pharmacy team had completed Dementia Friends training, so they had a better understanding of
people living with this condition.
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Principle 2 - Staffing aStandards met
Summary findings
Pharmacy team members work well together in a busy environment, and they have the right training
and qualifications for the jobs they do. Team members are comfortable providing feedback to their
manager and they receive informal feedback about their own performance.
Inspector's evidence
There was a pharmacist, three NVQ2 qualified dispensers (or equivalent), a trainee dispenser and a
trainee medicines counter assistant (MCA) on duty at the time of the inspection. The staffing level was
adequate for the volume of work during the inspection and the team were observed working
collaboratively with each other and the people who visited the pharmacy. Planned absences were
displayed on a holiday chart and organised so that not more than two dispensers were away at a time.
Absences were covered by re-arranging the staff rota when necessary. There was a delivery driver on
the pharmacy team. The RP worked two days on a regular basis and there was another regular
pharmacist who covered the other three days. The pharmacy was managed by the SI who visited the
pharmacy regularly. One of the dispensers was a supervisor who organised the pharmacy team and
allocated their duties.
Members of the pharmacy team carrying out the services had completed appropriate training. They had
access to online resources and were given regular protected training time. Each member of the team
had an individual folder where their completed training was recorded. One of the dispensers had
completed recent training on weight loss, blood pressure testing, diabetes, sepsis, cancer and
vaccinations.
Team members discussed their performance and development informally with their manager. Team
meetings were held when the SI visited the pharmacy and the supervisor kept brief notes to remind her
of the main points. A variety of issues were discussed, and concerns could be raised. Members of the
team confirmed they would be comfortable talking to the supervisor or SI about any concerns they
might have, and they were comfortable admitting and discussing mistakes they had made. There was a
whistleblowing policy.
The pharmacists were empowered to exercise their professional judgement and could comply with
their own professional and legal obligations. For example, refusing to sell a pharmacy medicine
containing codeine, because they felt it was inappropriate. The RP was encouraged to carry out
additional services such as the New Medicine Service (NMS) and vaccinations but was not under any
pressure to achieve targets.
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Principle 3 - Premises aStandards met
Summary findings
The pharmacy provides a professional environment for people to receive healthcare services. It has
a consultation room that enables it to provide members of the public with the opportunity to receive
services in private and have confidential conversations.
Inspector's evidence
The pharmacy premises, including the shop front and facia, were clean, spacious and in a good state of
repair. The retail area was free from obstructions, professional in appearance and had a waiting area
with two chairs. The temperature and lighting were adequately controlled. The pharmacy had been re-
fitted to a good standard, and the fixtures and fittings were in good order. Staff facilities included a
small kitchen area and a WC with a wash hand basin and hand wash. There was a separate dispensary
sink for medicines preparation with hot and cold running water. Hand washing notices were displayed
above the sinks. The consultation room was equipped with a sink, and was uncluttered, clean and
professional in appearance. This room was used when carrying out services such as vaccinations and
when customers needed a private area to talk.
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Principle 4 - Services aStandards met
Summary findings
The pharmacy offers a range of healthcare services which are adequately managed and easy for people
to access. The pharmacy generally sources, stores and supplies medicines safely. And it carries out
appropriate checks to ensure medicines are in good condition and suitable to supply.
Inspector's evidence
The pharmacy, consultation room and pharmacy counter were accessible to everyone, including people
with mobility difficulties and wheelchair users. The pharmacy team members were clear what services
were provided, but the services were not clearly advertised, so people might not realise what was
offered. There was a small range of healthcare leaflets with some information on mental health and the
Samaritans phone number. There were posters advertising local services. For example, the Leek peer
group.
There was a home delivery service with associated audit trail. The service had been adapted to
minimise contact with recipients, during the pandemic. The delivery driver confirmed the safe receipt in
their records. A note was left if nobody was available to receive the delivery and the medicine was
returned to the pharmacy.
Space was adequate and the workflow was organised into separate areas with a designated checking
area. The dispensary shelves were neat and tidy. Dispensed by and checked by boxes were initialled on
the medication labels to provide an audit trail. Different coloured baskets were used to improve the
organisation in the dispensary and prevent prescriptions becoming mixed up. The baskets were stacked
to make more bench space available.
The RP was aware of the valproate pregnancy prevention programme. He said original packs were
always supplied which contained the valproate care cards to ensure people in the at-risk group were
given the appropriate information and counselling.
Multi-compartment compliance aid packs were reasonably well managed. There was a partial audit trail
for changes to medication in the packs. But it was not always clear who had confirmed these and the
date the changes had been made, which could cause confusion to people assembling the packs, or if
there was a query. Medicine descriptions were added to the packaging if requested to enable
identification of the individual medicines. Packaging leaflets were not usually included. So, people might
not have easy access to all of the information they need. Disposable equipment was used. An
assessment was made as to the appropriateness of a pack or if other adjustments might be more
appropriate to the person's needs. For example, supplying in original packs with medicine
administration record (MAR) charts. New patients were only taken on if they had been referred by their
GP or another healthcare professional.
The trainee MCA explained that she always involved a qualified member of the pharmacy team when a
person requested a pharmacy (P) medicine. She was clear which medicines could be sold in the
presence and absence of a pharmacist, and she understood what action to take if she suspected a
customer might be abusing medicines such as a codeine containing product. A dispenser described
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what questions she asked when making a medicine sale and knew when to refer the person to a
pharmacist.
CDs were stored in two CD cabinets which were securely fixed to the wall. The keys were under the
control of the RP during the day and stored securely overnight. Date expired, and patient returned CDs
were segregated and stored securely. Patient returned CDs were destroyed using denaturing kits. P
medicines were stored behind the medicine counter so that sales could be controlled.
Recognised licensed wholesalers were used to obtain stock medicines. Medicines were stored in their
original containers at an appropriate temperature. Date checking was carried out, but this was not
always documented, so there was risk that some areas of the pharmacy might be missed. Short-dated
stock was highlighted. Dates had been added to opened liquids with limited stability. Expired and
unwanted medicines were segregated and placed in designated bins.
Alerts and recalls were received via email messages. These were read and acted on by a member of the
pharmacy team. But the action taken was not always recorded, so team members might not be able to
respond to queries and provide assurance that the appropriate action had been taken.
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Principle 5 - Equipment and facilities aStandards met
Summary findings
Members of the pharmacy team have the equipment and facilities they need for the services they
provide. They maintain the equipment so that it is safe and use it in a way that protects privacy.
Inspector's evidence
Current versions of the British National Formulary (BNF) and BNF for children, were available for
reference and the pharmacist could access the internet for the most up-to-date information. There
were two clean medical fridges. The minimum and maximum temperatures were being recorded
regularly and were within range. All electrical equipment appeared to be in good working order. There
was a selection of clean glass liquid measures with British standard and crown marks. Separate
measures were marked and used for methadone solution. The pharmacy had a range of clean
equipment for counting loose tablets and capsules, with a separately marked tablet triangle that was
used for cytotoxic drugs. Medicine containers were appropriately capped to prevent contamination.
Patient medication records (PMRs) were password protected. Cordless phones were available in the
pharmacy, so staff could move to a private area if the phone call warranted privacy.
What do the summary findings for each principle mean?
Finding Meaning
The pharmacy demonstrates innovation in the
way it delivers pharmacy services which benefit
aExcellent practice the health needs of the local community, as well
as performing well against the standards.
The pharmacy performs well against most of the
standards and can demonstrate positive
aGood practice outcomes for patients from the way it delivers
pharmacy services.
aStandards met The pharmacy meets all the standards.
The pharmacy has not met one or more
Standards not all met
standards.
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