| 20/03/2020 |
Failure to act on health and safety concerns |
Governance, Responsiveness |
Principle 1. Governance, Principle 2. Staff, Principle 3. Premises |
1.1, 2.5, 3.1 |
The pharmacy does not have a working fire alarm. And people in the pharmacy can’t hear the alarm in the adjoining health centre. This poses a health and safety risk to both staff and people visiting the pharmacy and adjoining health centre. The pharmacy does not have an appropriate waste management contract in place. This means that waste is accumulating and poses a risk to staff and the surrounding environment, where it is stored. |
Details
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| 31/12/2019 |
Equipment installed in a location where people’s privacy is not adequately protected |
Governance, Outcomes for patients |
Principle 5. Equipment and facilities |
5.3 |
The privacy and dignity of people who use the supervised consumption service is compromised by the position of the equipment and automated software system, used for dispensing and recording their medication. |
Details
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| 20/12/2019 |
Application of safety and quality monitoring processes to support shared learning |
Efficiency of processes, Governance, Leadership |
Principle 1. Governance |
1.2 |
Pharmacy team members act openly and honestly by sharing information when mistakes happen. And they engage fully in shared learning processes to help reduce identified risks. |
Details
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| 20/12/2019 |
Commitment to continual learning |
Governance, Leadership, Proactive approach, Responsiveness |
Principle 2. Staff |
2.2, 2.4, 2.5 |
Pharmacy team members are encouraged to develop skills relevant to their roles through continual training. And they use the skills they have learnt when engaging with people and providing pharmacy services. They are open to learning following their mistakes. And they work effectively together to ensure the pharmacy operates in accordance with professional standards. |
Details
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| 20/12/2019 |
Effective shared learning arrangements to improve patient safety. And continual development of the pharmacy team |
Efficiency of processes, Governance, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance, Principle 2. Staff |
1.2, 1.3, 2.2, 2.3 |
The pharmacy has robust safety processes. And its team members are committed to sharing learning to help continuously drive improvement. Pharmacy team members have clearly defined roles and responsibilities. And the pharmacy manages the risks associated with delegating its tasks well, through regular audit. The pharmacy has robust learning and development strategies which encourage pharmacy team members to expand their knowledge and skills. Pharmacy team members demonstrate how they apply their professional judgement and learning by working in specialised roles focussed on improving outcomes for the people using the pharmacy's services. |
Details
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| 19/08/2019 |
Management of the risks associated with distance selling of medication liable to addiction or abuse, using online prescribers. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.8, 4.2 |
Vulnerable patients have been supplied with medicines that are not clinically appropriate, excessive in quantity, and which have resulted in patient harm, or other serious risk to patient safety. |
Details
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| 19/08/2019 |
Inadequate identification and management of the risks associated with the provision of medicines to people overseas. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 3. Premises, Principle 4. Services, including medicines management |
1.1, 1.2, 1.3, 1.6, 1.8, 3.1, 4.2, 4.3 |
The pharmacy does not adequately identify and manage the risks associated with the provision of medicines to people overseas. It does not check the identity of patients, or ensure that higher‐risk medicines, including methotrexate and misoprostol, are supplied safely. Pharmacy professionals involved in the supply of medicines overseas do not fully understand their responsibilities or accountabilities. The pharmacy does not make accurate or complete records about the supplies it makes of prescription‐only medicines to patients overseas. It also does not adequately monitor the temperature of medicines which require cold storage. |
Details
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| 15/08/2019 |
Efficiency and safety of processes assured through sound risk assessment and use of staff skills. |
Customer and patient focus, Efficiency of processes, Governance, Innovation, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance |
1.1, 1.2, 1.3, 1.6 |
There is an innovative approach taken to using the Accuracy Checking Technician’s skills, enhanced use of the pharmacy team and thorough and robust record keeping to free up pharmacists’ time to deliver additional services safely, while ensuring that the dispensing and supply of medicines remains safe, and compliance and medicines optimisation is addressed. |
Details
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| 15/08/2019 |
Safeguarding vulnerable patients |
Customer and patient focus, Efficiency of processes, Governance, Outcomes for patients, Proactive approach, Responsiveness |
Principle 1. Governance |
1.8 |
Safeguarding vulnerable patients is a clear focus for the pharmacy team. |
Details
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| 15/08/2019 |
Innovative dementia support services |
Customer and patient focus, Governance, Innovation, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 4. Services, including medicines management |
4.1, 4.2, 4.3 |
A range of extended services for people with dementia and their families is aligned to patients' needs and expectations and ensuring patient safety and effective care across all services. |
Details
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| 15/08/2019 |
Staff development and training supported by a strong learning culture. |
Customer and patient focus, Governance, Innovation, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 2. Staff |
2.1, 2.2, 2.3, 2.4, 2.5 |
There is a strong emphasis on training (including extended technician training), development and communication to ensure that highly qualified and skilled individuals are utilised to deliver innovative services to benefit the local community. |
Details
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| 09/08/2019 |
Effective use of monitoring and review mechanisms and a culture of learning from incidents. |
Customer and patient focus, Efficiency of processes, Governance, Leadership, Proactive approach |
Principle 1. Governance |
1.1, 1.2 |
The pharmacy demonstrates a robust and systematic approach to clinical governance. Risks to pharmacy services are proactively identified and managed. Systematic review procedures are applied with risk reduction actions implemented routinely. |
Details
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| 09/08/2019 |
Use of new technology to improve efficiency and effectiveness |
Added value, Customer and patient focus, Efficiency of processes, Governance, Innovation, Leadership, Outcomes for patients, Proactive approach, Responsiveness |
Principle 5. Equipment and facilities |
5.1, 5.2 |
Dispensing is highly automated using 2 robots which are maintained and serviced regularly and providing an efficient dispensing process. There is a range of high specification equipment for extended services which is calibrated and PAT tested annually. These are used in consultation rooms protecting the privacy and dignity of patients. |
Details
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| 09/08/2019 |
Joint working with local GPs to ensure more effective treatment of patients with chronic conditions. |
Added value, Customer and patient focus, Governance, Innovation, Leadership, Outcomes for patients, Proactive approach |
Principle 4. Services, including medicines management |
4.1, 4.2, 4.3 |
Joint working with local GPs to ensure more effective treatment of patients with chronic conditions. |
Details
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| 09/08/2019 |
Working proactively to safeguard vulnerable adults and children |
Customer and patient focus, Governance, Outcomes for patients |
Principle 1. Governance |
1.8 |
The pharmacy considers safeguarding in all aspects of its service delivery. Waiting areas promote wellbeing through innovative promotion of lifesaving information. The pharmacy identifies the most vulnerable people and works collaboratively with other organisations to safeguard these people whilst also considering the safety precautions it must take to protect its own staff. |
Details
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| 09/08/2019 |
Inadequate risk assessment of monitored dosage system dispensing in a closed pharmacy |
Efficiency of processes, Governance, Lack of key knowledge and a failure to learn, Outcomes for patients |
Principle 4. Services, including medicines management |
4.2 |
The pharmacy has not assessed the risks associated with the supply of multi-compartmental compliance devices to people. The devices are not labelled appropriately, and some are labelled and assembled before the prescription arrives at the pharmacy. There is a risk that people will not receive the correct information they require to take their medicine safely. There is also a risk that changes to medicine regimens may not be checked or addressed. |
Details
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| 09/08/2019 |
Weaknesses in the identification and management of risks to patient safety. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance |
1.1, 1.6, 1.7 |
The pharmacy has not risk assessed how some parts of the pharmacy service provided by a third-party supplier are managed. Nor does it monitor information provided on its website. This means that there is little assurance that the pharmacy is protecting the safety and wellbeing of people who may access its services through the website. |
Details
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| 09/08/2019 |
Lack of assurance about the safety of remote dispensing services. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.5, 1.8, 4.2 |
The pharmacy has no assurance that the remote prescribing service it uses is safe. It has not checked that the prescribers it works with are competent, can lawfully issue prescriptions to people in the UK and are covered by appropriate indemnity arrangements. |
Details
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| 09/08/2019 |
Preventing abuse of medication |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.5, 1.8, 4.2 |
The pharmacy is not following its own policies and procedures intended to prevent abuse of medication. |
Details
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| 09/08/2019 |
Insufficient information to enable an informed decision about treatment and about how to raise concerns. |
Customer and patient focus, Governance, Lack of key knowledge and a failure to learn, Leadership, Outcomes for patients |
Principle 1. Governance, Principle 4. Services, including medicines management |
1.1, 1.5, 1.8, 4.2 |
There is insufficient information for the public about the prescribing service to make an informed decision, or raise concerns about the quality of the service. |
Details
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