Inspection outcomes

A pharmacy will receive an overall outcome from its inspection, and findings about each of the five principles that make up the standards for registered pharmacies. If it does not meet all of the standards, the pharmacy will need to complete an improvement action plan.

Potential inspection outcomes

There are two potential outcomes from an inspection:

  • standards met
  • standards not all met

All of the standards for registered pharmacies need to be met for a pharmacy to receive a ‘standards met’ outcome. Any pharmacy not meeting all of the standards will need to complete an improvement action plan.

The improvement action plan will be published alongside the inspection report on our Inspections website.

The pharmacy will also receive one of four possible findings for each of the five principles within the standards for registered pharmacies.

The four possible findings are:

  • ‘excellent practice’
  • ‘good practice’ 
  •  ‘standards met’
  • ‘standards not all met’

This will help the pharmacy owner and the team to understand the positive areas of practice from the inspection, as well as areas for improvement.

Having these four findings at principle level enables us to identify notable practice – good and excellent practice our inspectors are seeing during inspections, as well as poor practice.

Our inspectors consider the Findings framework when assessing how to make findings against the five principles.

Our Inspections website includes a knowledge hub featuring these examples of notable practice, as a learning resource for people working across the pharmacy sector. This helps to support continuous improvement across pharmacy for patients and the public.

Improvement action plans and enforcement action

Our overall approach is to support and encourage pharmacy owners to meet the standards for registered pharmacies.

We have several different enforcement options available to us to secure compliance with our standards. These range from improvement action plans to statutory enforcement powers, including improvement notices and conditions on registered pharmacy premises.

Improvement action plans

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

The pharmacy would be expected to tell us within five working 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 are published on the Inspections 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 final inspection report was sent to the owner.

At the six-month re-inspection, the inspector will visit the pharmacy again to assess whether the pharmacy is meeting standards and that improvements are being sustained.

If that is the case, 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 website, once it has been through our quality assurance process.

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


Statutory enforcement powers

We 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,
  • there is a serious risk to patient safety

We have legal powers to put conditions on a registered pharmacy when this is necessary to make sure it is operating safely and effectively. We can put these conditions on the pharmacy when it becomes registered, or at any point while it is on our register.

Requesting that conditions are removed or changed

Pharmacy owners can ask for a condition (or conditions) put on a pharmacy to be removed, or changed. To ask for this:

  • Complete the Applying to vary or revoke conditions on a pharmacy premises form. Read the guidance that comes with the form to make sure your application includes the information we need, in the right format.
  • Provide supporting documents, information or evidence for your request.
  • Post your completed application form and supporting documents to the us at the address on the form.