Free SOP Health Check

1. Do you have a written SOP for every activity and service the pharmacy provides, including services such as Pharmacy First?

2. Have all SOPs been reviewed within the last two years, or sooner after a change in practice?

3. Is the RP notice displayed and the Responsible Pharmacist record complete every day?

4. Are near misses and dispensing incidents recorded and reviewed regularly for learning?

5. Are patient safety alerts and drug recalls actioned and the action recorded?

6. Has every member of staff, including locums, read and signed the SOPs for their role?

7. Are training records and a "who can do what" competence list up to date?

8. Does every member of staff know how to raise a safeguarding concern and who to contact?

9. Are fridge temperatures (current, minimum and maximum) recorded every working day, with a clear plan for excursions?

10. Are CD running balances checked regularly and every discrepancy investigated?

11. Is CD destruction witnessed by an authorised person and recorded correctly?

12. Is date checking done to a documented rota?

13. Do you have a business continuity plan for IT or EPS outage, power loss and fridge failure?

14. Is the DSPT submitted and are staff trained in information governance?

15. Is there a cleaning schedule and infection control procedure that staff follow?

16. Could you show an inspector evidence of all of the above within ten minutes?

1. Are all policies and SOPs in date, with a record of which staff have read them?

2. Are statutory notifications made to CQC without delay, and logged?

3. Are incidents and accidents reviewed each month for trends and learning?

4. Is there a regular provider or manager quality audit with an action plan that is followed up?

5. Are MAR or eMAR records complete, with refusals and omissions coded and escalated?

6. Are medicines room and fridge temperatures recorded daily, with action taken when out of range?

7. Are controlled drugs checked regularly by two staff, with discrepancies investigated?

8. Does every resident prescribed a "when required" (PRN) medicine have a PRN protocol?

9. Are mental capacity assessments and best-interests decisions recorded where a resident cannot consent?

10. Is your DoLS register up to date, including expiry dates and conditions?

11. Do all staff know how to recognise and report abuse, and are referrals tracked to their outcome?

12. Are falls, pressure ulcer, nutrition (MUST) and choking risks assessed and regularly reviewed?

13. Do staff use a structured tool such as RESTORE2 or NEWS2 to recognise and escalate deterioration?

14. Are recruitment files complete (DBS, references, right to work, employment gaps explained)?

15. Is mandatory training, including Oliver McGowan training, up to date for everyone?

16. Are fire drills (including night staff), PEEPs and weekly fire alarm tests done and recorded?

17. Are hoists and slings thoroughly examined every six months under LOLER and checked before each use?

18. Are water temperatures and Legionella controls checked and recorded?

19. Are cleaning schedules and infection control audits completed, with an outbreak plan ready?

1. Are SOPs and policies in date and signed by every team member, including locums?

2. Are significant events recorded, discussed with the team and learned from?

3. Do you run a clinical audit programme that includes radiography and infection control?

4. Are autoclave daily tests (and steam penetration tests for vacuum autoclaves) done and logged every day?

5. Is decontamination equipment validated at least annually?

6. Is the six-monthly infection control audit completed with actions followed up?

7. Are dental unit waterlines flushed and treated, with records kept?

8. Are emergency drugs, oxygen and the AED checked at least weekly, with records kept?

9. Does the whole team complete medical emergency and BLS training at least once a year?

10. Is your radiation protection file complete (RPA appointed in writing, local rules, risk assessment, HSE registration)?

11. Are your IR(ME)R employer's procedures up to date, including the 2024 requirements on referrals?

12. Are routine X-ray equipment tests and radiograph quality audits up to date?

13. Is consent properly recorded, including for children and patients who may lack capacity?

14. Does everyone know the safeguarding lead and how to make a referral?

15. Are GDC registration, DBS checks and hepatitis B immunity recorded for all staff?

16. Do staff know exactly what to do after a sharps or inoculation injury?

17. Is waste segregated and consigned correctly, including amalgam, with an amalgam phase-down plan?

18. Is there a current Legionella risk assessment with water temperatures monitored?