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Pharmacy inspections

Inspection reports and learning from inspections

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Air Balloon Pharmacy (1028674) - Improvement action plan

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

The pharmacy is under new ownership and there are no written procedures on the premises for the team members to refer to. This means that services may not be delivered safely.

The SOPs had already been delivered to the pharmacy, they have been printed now and a copy has been saved on the computer so they can be easily accessed when required.
The staff are working through them at the moment, they will be read and signed within ten working days.

06/01/2020 23/01/2020
1.2

There are no procedures in place to reflect and learn from mistakes.

Enforce the use of the near miss log that had not been used for months by the previous employer. The pharmacist will reviewe each week and speak with each staff regarding the near miss to see if they need any extra training or support as stated in the SOP.

06/01/2020 23/01/2020
1.4

There are no systems in place to deal with complaints or feedback from people.

The step by step procedure is detailed in the “Dealing with a complaint” SOP.
Both the pharmacy leaflet and the practice poster have been updated so the procedure is easily available to members of the public.

06/01/2020 23/01/2020
2.1

The pharmacy has no procedures to accommodate staff illness. The team are not told when staff members who leave will be replaced. This puts them under pressure.

The company is aware that more staff need to be recruited. We have tried since we took over, unsuccessfully. Recruitment is still ongoing.
In the meantime, staff have been given overtime and two locum dispensers have been booked.
The pharmacist and a locum dispenser worked on the 15/11/19 to catch up with workload.
Last minute emergency days off can be covered by moving staff from the nearby branch (less than 5 miles) in BS5 7PD or from the branch in GL11 4JN, 40minutes away, if from the first one is not possible. Locum dispensers can be recruited again if needed.

06/01/2020 06/01/2020
2.5

The team members are not supported by the company. There are no clear lines of communication with higher management. The team members have raised legitimate concerns with their immediate manager but these have not been acted on.

The pharmacist manager worked in the branch everyday in November and three times a week from December, he rings in every day that he doesn’t work in the branch.
The “Whistle blowing” policy is in place and a contacts list, including the superintendent pharmacist and company directors, has been displayed in the pharmacy.

06/01/2020 06/01/2020
4.2

Some people may not be given the information that they need to use their medicines safely.

A ‘Speak to the pharmacist’ label has been ordered to flag up all high-risk medicine and whenever the pharmacist would need to talk to the patient before handing it out.
The Sodium valproate pack is ordered, and briefed with each staff and the audit is started immediately.
Regarding the handwritten labels, it only happened on the 1st of November for prescriptions that could not wait until the following day, whilst the new software was installed. All the prescriptions dispensed that day were processed using the new software on the following day.

06/01/2020 23/01/2020
4.4

The pharmacy team members cannot show that people only get medicines or devices that are safe.

Date checking folder is now set up and medicines are checked every three months as per SOP.
The pharmacy has signed up to the MHRA to receive medicines alerts and updates. All alerts and recalls will be printed, check against current stock (or dispensed if “patient level”), signed and dated.
Hardware compatible with FMD is in place.
The pharmacy has requested the validation code from Securmed UK to activate the FMD module in the dispensing software (Proscript).

06/01/2020 06/01/2020