Peasedown Pharmacy (1028534) - Improvement action plan

The pharmacy team do not manage and protect people’s confidential information adequately.

- All colleagues to re-read the company Information Governance folder and resign to confirm understanding.
- Confidential waste to be minimized through conscientious action, and a rota setup to ensure consistent shredding. Colleagues reminded that failure of shredder/excess shredding can be securely bagged and returned to Shaunak House for appropriate destruction.

The pharmacy does not adequately maintain all of the records it must keep by law.

- Responsible Pharmacist log to be kept on dispensing bench at end of day near the “checking are” so pharmacist next day is prompted to sign in.
- Area manager audit will include a check of the RP logs.
- Fridge Temperature checks to be put on rota to ensure is completed daily.
- Pharmacy team to ensure Near Misses are completed daily, Pharmacist to sign log if at the end of the day if there has no near misses.
- Drug Alerts folder created, all alerts to be signed to indicate action/no action by RP on day of alert.
- Scheduled CD checks to be implemented on a Bi-Weekly basis.
- The CD cabinet has been checked by the RP & the superintendent and all issues have been resolved.
- Lexon Specials folder to be actively used to maintain all records.

The pharmacy does not store all of its medicines safely and in accordance with the law.

- All colleagues to re-read and sign SOP “Safe and Effective Disposal of Medicines”, Patient return tray to be in use, accompanied with list of accepted waste and hazardous material.
- Cytotoxic bin in location all colleagues are aware of, and to be accompanied by list of hazardous waste that should be used for that bin.
- Medicine Shelving rota to be setup, to ensure clean and efficient storage of medicines.
- LASA to reviewed to ensure risk is managed with similar medicines. Notes should be added to shelf edging.
- Team reminded on storage of drugs without original container, and information that must be captured to retain that drug, and failure to hold that information will result in destruction of drug.
- All pre-prepared CD’s awaiting patient collection including daily methadone will be stored in the CD cupboard.
- Valproate patient cards to be ordered in for use.