Tolerances in meeting the standards

The indicators under each standard are just that, examples to indicate that the standard is being met.

This is not a checklist but part of the way we help to ensure consistency across inspections. If a pharmacy does not provide a particular service or have the same process in place as described by an indicator in the inspection decision framework but is able to provide evidence of a different way they meet the standards that is absolutely fine. 

If we believe that the evidence shows that a standard has not been fully met, but is an isolated and easily rectified issue that, most important, poses no significant risk to patient safety, this will be an ‘acceptable tolerance’ and the standard will be considered ‘met’.  When making a judgement, our inspectors will look across all of the evidence, including where there are deficiencies, and assess the overall picture. The deficiency will still be recorded and we will expect action to be taken to ensure that all standards are being achieved.

Example: cleanliness

The level of cleanliness (and indeed hygiene) needs to reflect the nature of the services provided and the clinical risks involved. An example of this could be where there are invasive treatments such as flu vaccinations. Our inspectors may look for different things compared to a pharmacy selling P medicines over the counter. There is no requirement for cleaning logs but if they are in place this is positive evidence of a planned approach. However, it should be remembered that cleanliness is part of a standard that also includes safety, maintenance and suitability of the premises, so any judgement the inspector makes will encompass all these dimensions.

The important thing to remember is that our approach to inspection is about improvement. We are looking for the overall picture, we are not seeking to penalise minor issues when, added up together, they do not pose a high risk to patient safety.