G P h C P RI N C I P L E 1 : ACT I O N P L A N
The governance arrangements safeguard the health, safety and wellbeing of patients and the public
1 .1 THE RISKS ASSOCIATED WITH PROVIDING PHARMACY SERVICES ARE IDENTIFIED AND MANAG ED
Question
1 Has each member of the team completed
all the SOPs relevant to their role and
confirmed that they have been read and
understood?
2 Business Continuity Plan - Is the latest
version in place (updated annually)
and does this include branch specific
information? [All colleagues should be
familiar with this plan and its location]
3 Has a Service Implementation Risk
Assessment been completed for each
service offered?
1 .2 THE SAFETY AND QUALITY OF PHARMACY SERVICES ARE REVIEWED AND MONITORED
Question
4 Is there evidence of near misses being
logged?
Details of action required Reference Comments Actioned
Once each SOP is read, sign and date the Numark SOPs
SOP record sheet. - by signing against the
SOP you are signing to say you have read
and understood the SOP.
In order for the Business Continuity Plan Numark Business
to be effective, it is essential that all Continuity Plan
pharmacy team members are aware of
the details of the plan and know when to
consult it.
Complete a risk assessment for any Numark Risk
service that the pharmacy offers. assessment
template
Details of action required Reference Comments Actioned
A Near Miss Log must be in place in the Numark Dealing
pharmacy and a new page should be used with near misses
each month. An entry on the Near Miss and errors SOP
Log sheet must be made for each near
Numark Dealing
miss at the time it is discovered. Each
with near misses -
near miss identified must be highlighted
Dispensing Errors
to the colleague responsible as soon as
Log
practicable after it has been identified. All
columns need to be completed on the Near
Miss Log sheet, with details of corrective
action recorded for each near miss.
5 Is there evidence that both the Monthly
Safety Review Log and Monthly Patient
Safety Review have been completed?
6 Do appropriately trained colleagues
working in the dispensary understand
the process to follow when a CD balance
discrepancy is identified?
7 Do all colleagues working in the dispensary The dispensary team must be able to
know how to report a Patient Safety
Incident (PSI)?
8 Have the team fully completed all
stated actions undertaken to prevent
reoccurrence of error as detailed in the PSI
report?
At the end of the month, the pharmacist Patient safety
(and / or a designated suitably qualified
colleague) should review the Near Miss Log
sheet and from this review complete the
Monthly Safety Review Log. Completion
of the Monthly Safety Review Log will
help to identify trends and patterns over
a 12 month cycle. This data should then
be used to complete the Monthly Patient
Safety Review. It is important that specific
learnings are identified and your team
must list your three safety priorities for
the next month. As part of your Monthly
Patient Safety Review, it is essential that
you check that you have implemented all
actions documented on the Near Miss Log
/ Patient Safety Incident Reports.
It is the responsibility of the Responsible Numark CD5
Pharmacist on the day the discrepancy - Recording
became known to investigate. Concerns on the
Management of
CDs SOP
Patient Safety
explain how to complete a PSI report, Incident Report
however, the report should ideally be Form
completed by the pharmacist.
Investigations following a Patient Safety Numark Patient
Incident will take place and examine the safety incident
circumstances surrounding the incident. follow up guidance
How they occurred, the actions taken at
the time and subsequently, what lessons
have been learned and what procedures
have been put in place to prevent a similar
incident from occurring in the future. It is
important that these learnings are put
into practice otherwise allegations of
negligence could be made if errors occur
repeatedly.
1 .3 PHARMACY SERVICES ARE PROVIDED BY STAFF WITH CLEARLY DEFINED ROLES AND CLEAR LINES
OF ACCOUNTABILITY
Question Details of action required Reference Comments Actioned

9 Is the correct Responsible Pharmacist (RP) The pharmacy record is an important legal The Responsible
notice displayed and is the RP signed into document. The RP notice must state your Pharmacist Notice
the legal RP record? name and registration number and be
GPhC -
placed conspicuously in the designated
responsible
area for the RP notice.
pharmacist notice
10 Is the RP record completed fully and up to Complete the pharmacy record. The record Responsible
date? may be in electronic or paper form and Pharmacist
meets the legal requirements.

11 Are staff aware of their roles and what Staff aware of their roles, including the role Numark Absence
they can do when there is no RP? of the RP and know what to do if the RP is of Responsible
absent. Pharmacist from
the pharmacy SOP
Responsible
pharmacist duties

1 .4 FEEDBACK AND CONCERNS ABOUT THE PHARMACY, SERVICES AND STAFF CAN BE RAISED BY INDIVIDUALS
AND ORGANISATIONS, AND THESE ARE TAKEN INTO ACCOUNT AND ACTION TAKEN WHERE APPROPRIATE
Question Details of action required Reference Comments Actioned

12 Complaints procedure – Can all colleagues All colleagues need to have read and Numark Dealing
explain the complaints procedure. understood the complaints procedure. with complaints
SOP (England &
Wales)
Numark Dealing
with Complaints
SOP (Scotland)
13 Are there copies of the practice leaflet These should be readily available for Practice leaflet
available customers to obtain.
14 Can the team give any examples of
feedback they have received and any
changes made as a result of this?
Patients are routinely involved in shaping
and improving pharmacy facilities and
services. Pharmacy to show that it
has made improvements to pharmacy
services following feedback leading to
positive outcomes for patients. Customer
testimonials, letters and cards are all good
examples to share with the inspector.

1 .5 APPROPRIATE INDEMNITY OR INSURANCE ARRANG EMENTS ARE IN PLACE FOR THE PHARMACY SERVICES
PROVIDED
Question Details of action required Reference Comments Actioned

15 Poster Display The posters that can be displayed in the Health and safety
dispensary are as follows: poster
• Employers Liability Certificate.
• Professional Indemnity Certificate.
• Health and Safety Law poster.

1 .6 ALL NECESSARY RECORDS FOR THE SAFE PROVISION OF PHARMACY SERVICES ARE KEPT AND MAINTAINED
Question Details of action required Reference Comments Actioned

16 Is the CD balance check being completed The stock levels for all schedule 2 CDs Numark CD3-
correctly? must be checked each week. Please note, Stock control and
the weekly check does not have to be record keeping
carried out all at once on the same day - SOP
smaller sections may be checked each day,
so long as all items are checked once each
week. Please note that date expired stock
must continue to be balance checked as
per SOP until it is denatured.
17 Are all headings completed for each CD Legislation requires that the class, strength Numark CD3-
register page? and form be specified at the head of Stock control and
each page of the CD register. Ensure the record keeping
headings are completed in FULL not just SOP
the drug name and this must be on every
page.
18 Is the CD register free from obliterations
and alterations? Corrections must be
made using footnotes, dated and initialed
by the pharmacist and include the
pharmacist’s GPhC number
19 Are patient returned controlled drugs
recorded on receipt and is destruction
properly documented and witnessed?
20 Does the POM register contain
appropriate entries corresponding with
the filed private prescriptions?
No cancellation, obliteration or alteration Numark CD3-
may be made. Corrections must be made Stock control and
by dated footnotes and initialed by the record keeping
pharmacist and include the pharmacist’s SOP
GPhC number. If an amendment needs
to be made in the CD register, place
an asterisk (*) next to the register entry
containing the error.
Enter details of the amendment as a
footnote next to another asterisk (*) at the
bottom of the page.
A record of all schedule 2 patient Numark CD4-
returned drugs must be kept. The patient Disposal of
returns register must then be updated unwanted CD SOP
once denaturing has occurred and the
following information recorded: the date of
destruction / the initials of the pharmacist
destroying the CDs / the initials of the
person witnessing the destruction of the
CDs. Schedule 3 patient returns are not
legally required to be entered into the
returns register.
The following detail must be recorded Numark
in the POM register for each private Dispensing private
prescription dispensed; the date the prescriptions SOP
medicine was supplied / the details of
the medicine supplied / the date on the
prescription / the name and address of
the prescriber / the name and address
of the patient / the payment taken for
the medicine. If repeatable this should
also include the sequential number of
dispensing.
21 Are emergency supplies at the request of
the prescriber / patient correctly recorded
in the POM register?
22 Specials Folder - Is there a Certificate of
Conformity (COC) / Analysis (COA) record
kept for Specials? Are all COC and COA
completed in full?
A) Request of the prescriber - the date the Numark
POM was supplied / the name (including Emergency supply
strength and form where appropriate) and of POM SOP
quantity of medicine supplied / the name
and address of the prescriber requesting
the emergency supply / the name and
address of the patient for whom the POM
was required / the date on the prescription
/ the date on which the prescription is
received.
B) Request of the patient - the date the
POM was supplied / the name (including
strength and form where appropriate) and
quantity of medicine supplied / the name
and address of the patient for whom the
POM was supplied / information on the
nature of the emergency such as why
the patient needs the POM and why a
prescription cannot be obtained.
Ensure you have a specials folder where Specials
you keep all your documents and records.
These records have to be maintained in
accordance with the MHRA regulation.
You should record the information required
legally utilising the COC as the method
for recording specials procured. It is a
good idea to keep a copy of the legal
requirements in the front.
1 .7 INFORMATION IS MANAG ED TO PROTECT THE PRIVACY, DIG NITY AND CONFIDENTIALITY OF
PATIENTS AND THE PUBLIC WHO RECEIVE PHARMACY SERVICES
Question Details of action required Reference Comments Actioned

23 Does the pharmacy have in place policies All staff to read and signed the policies. Information
for Information Governance? Governance and
The Information Governance Toolkit was
Data Security and
updated in 2019 to include the General
Protection
Data Protection Regulations (GDPR) and
the National Data Guardian’s ten data Numark Data
security standards and is now called the Security and
Data Security and Protection (DSP) toolkit. Protection Policy
Numark Data
Protection Impact
Assessment
Template
GDPR
24 Are all team members aware on how Each team member should understand Numark
to report any Information Governance how to report an incident and the timelines Information
incidents? involved. All incidents which have, or could security incident
have, resulted in the loss of information management
(electronic or paper), unplanned procedure.
destruction of information, unauthorised
Numark
access to information or a threat which
Information
could have put the PMR system at risk, are
security incident
to be reported.
report form
25 Is the Privacy Notice on display where A Privacy Notice should be displayed Numark Privacy
patients and customers can easily see and within the branch so that it can be easily notice template
read it? Are the pharmacy team aware of seen.
the process to follow if a patient wants to
know what happens to their information?

26 Is all confidential waste shredded before No confidential waste should be placed in

being placed into the general waste bins? the general waste bin prior to shredding.
Shredding of confidential paperwork
should be scheduled into the working day
to avoid a large backlog of document.
27 Does the delivery driver confirm the
patient’s name and address at the point
of handover? What do the delivery drivers
use for patient signatures and any special
instructions?
28 If key codes are in use for patient’s
properties, do the pharmacy team have
written consent to hold this information?
29 If key codes are in use for patient’s
properties, it must not be printed on the
patient’s label, recorded in the delivery log
or written down or stored elsewhere with
the patient’s name and / or address
30 Are the pharmacy team fully compliant
with the transfer of the monthly
prescription bundle to their courier?
The pharmacy team must understand the Numark Delivery
procedure followed for failed deliveries service SOP
and the safeguards in place for delivery
to a different address or neighbour. The
delivery logs must contain; an address
label containing the patient details / any
messages for the patient or representative
/ any special instructions such as CDs
or fridge items should be highlighted.
The patient or representative must sign
against their details in the delivery log.
If they are unable to sign (in exceptional
circumstances) the driver may handover
the medication but must annotate the
delivery log stating that they have been
advised they are unable to sign - in which
case the delivery driver may sign on the
patient’s behalf.
Get written consent to use key codes and Numark Delivery
store securely in pharmacy. service SOP
Where a key safe / code is being used, Numark Delivery
the code for the keysafe or the door lock service SOP
MUST be recorded on the patient’s PMR.
Information regarding the code for the key-
safe or door lock needs to be kept securely
and should not be included on the bag
label or in the delivery book as if either is
lost the patient’s security is compromised.
The prescription bundle poses a high risk to CPE prescription
data protection and as such all pharmacy submission
members should be aware of the process requirements
to be followed.
1 .8 CHILDREN AND VULNERABLE ADULTS ARE SAFEGUARDED
Question Details of action required Reference Comments Actioned

31 Safeguarding children and adults at risk All pharmacy colleagues need to read Numark
policy: and sign the safeguarding children and Safeguarding
adults at risk policy and know where this policy for the
1. Have all team members read and
is located. Appendix 1 must be completed protection of
signed?
to provide local contact details. Your local children, young
2. Are the local safeguarding details surgery will often hold your local contact people and
completed in appendix 1? details should you not have them. vulnerable adults
3. Do all team members know where to
locate the policy?
32 Safeguarding Scenario - Pharmacy staff Specific feedback and actions will be given Numark
must be able to clearly describe ‘red flags’ to the colleague, all team members must Safeguarding
that would raise a concern and then be familiar with the Safeguarding Policy policy for the
describe what action they would take. and know where to locate this information. protection of
children, young
people and
vulnerable adults