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Improvement action plans

All pharmacies which have not met one or more of the standards during an inspection will be required to complete and implement an improvement action plan.

The pharmacy would be expected to tell us within 5 days of the action they intend to take to meet the standards and improve practice in the pharmacy. We will consider some flexibility in this timescale if there are exceptional reasons why this deadline cannot be met.

We require improvement action plans to be filled in by the owner and superintendent pharmacist and returned to us. The inspector will already have identified whether the improvement action in relation to each standard, must be completed within 10, 20 or 60 working days. The pharmacy owner and superintendent will identify when the actions will be completed within these timescales and who will be responsible for this. Pharmacy owners and superintendent pharmacists will be expected to action their improvements as soon as possible, especially where a risk to patient safety has been identified.

Improvement action plans will be published on the new inspections publication website alongside the inspection report.

Next steps

When the actions set out in the improvement action plan have been completed, the owner or superintendent pharmacist must notify us. Once the inspector is satisfied that evidence has been provided that indicates completion of the improvement action plan, a new inspection will be scheduled six months from the date when the inspection report was sent to the owner.

At the 6-month inspection, the inspector will visit the pharmacy again to assess whether the pharmacy is meeting the standards and that the improvements are being sustained. If that is the case, then we will issue an updated report with the new overall outcome showing that the pharmacy has met all of the standards. This report will be published on the inspection publication website, once it has been through the usual pre-publication process.

The previous inspection report(s) would be available in a section showing previous inspection history.

See our flowchart showing the process we follow when a pharmacy has not met all of the standards

Click on the preview image below to open the full diagram (opens on a separate window - you will be able to scroll up and down and zoom in and out).

This diagram explains the process when a pharmacy has not met all of the standards and has to complete an improvement action plan. It explains that the pharmacy owner has to notify the inspector once the improvement action plan is completed and give the inspector evidence and/or confirmation of the action taken. The inspector would then close the improvement action plan and schedule a re-inspection for 6 months after the report was finalised. If the pharmacy owner does not complete the improvement action plan, other enforcement actions will be considered.

The diagram is also available to download in pdf format.

We can use our statutory enforcement powers in situations when a pharmacy owner does not complete an improvement action plan and carry out the necessary changes to make sure our standards are met. Find out more about our approach to enforcement action