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Pharmacy inspections

Inspection reports and learning from inspections

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A.H. Hale Ltd. (1028531) - Improvement action plan

GPhC Reference 1028531

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

The pharmacy does not identify and manage risk well. There are no procedures in place to learn from mistakes.

A near miss log has been obtained from the NPA to help enable record and audit near misses. Previously, near misses were logged on a RPS template not seen at the time of inspection and actioned upon. The log is to be reviewed on a regular basis to further minimise and manage any incidence of near misses.
Dispensing errors, of which we’ve had none, will be recorded on the PMR computer and analysed on a per incident basis and reported as necessary to the relevant auothorities.
Dispensing staff have been reminded to initial boxes to help facilitate audit trails especially in case of the above.
RP SOP to be included in the SOP file so all staff are aware of their roles and responsibilities in the absence of the pharmacist and all other scenarios.

 28/05/2019 16/07/2019
1.6

The pharmacy does not maintain the necessary records it needs to by law.

Private prescriptions will now be only recorded electronically and filed with the corresponding serial number and no longer written in the book.
Emergency supplies will be recorded in the book to correspond with the PMR only.
A separate date checking diary will be kept and maintained instead of the current system.
A separate file will be kept and maintained for Specials products.

 28/05/2019 16/07/2019
1.7

The pharmacy does not manage information to protect the privacy of its patients.

A cross cut shredder has been installed to replace the current shredder.

 28/05/2019 16/07/2019
3.1

Some areas in the pharmacy are very untidy and represent a trip hazard to staff.

Occupying a grade II listed building brings its own challenges but steps have been taken to clear floor space and de-clutter storage areas.

 28/05/2019 16/07/2019
4.3

The pharmacy does not store medicines in accordance with the law. Unlabeled monitored dosage system trays are stored prior to the prescription arriving in the pharmacy.

As above. A new system has been put in place to ensure no MDS trays are left unlabeled. Extra prescriptions have been requested to help achieve this.
All staff reminded and briefed that no tablet blisters should be left on the shelf without being boxed and with the relevant information.

 28/05/2019 16/07/2019
4.2

Pharmacy services are not managed and delivered safely and effectively. The pharmacy does not routinely use audit trails to show who has dispensed and checked the medicines that they dispense. Monitored dosage system trays are filled in advance and then labelled at a later stage which may increase the risk of mistakes.

A hazardous waste bin has been obtained in addition to the already existing DOOP(drug waste) bins.
All dispensing staff to initial dispensed and checked boxes routinely as per SOP.
All MDS trays to be labelled at the point of dispensing. Surgery staff have been notified that we would require prescriptions for MDS patients in advance to help facilitate this so we are not anticipating prescriptions and can therefore manage dispensing workload according to legal requirements.

 28/05/2019 16/07/2019
5.1

The pharmacy does not have the appropriate equipment to provide the services offered.

In addition to the 100ml stamped measure currently in use, two smaller measures have been obtained from the NPA.

 28/05/2019 16/07/2019
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