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Pharmacy inspections

Inspection reports and learning from inspections

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Shaunak's Pharmacy (1028745) - Improvement action plan

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

The pharmacy team do not manage and identify risks well.

-LASA to be reviewed and updated
-Dedicated checking area for pharmacist
-Amy to hold monthly colleague huddles, discussing incidents, trends and findings from near miss review, and review any actions from previous meeting.

30/09/2019 14/10/2019
1.2

The pharmacy team do not review and monitor the safety and quality of pharmacy services.

-Near miss, and dispensing incident reviewed monthly and findings shared in team huddle.
-Additional colleague to learn MDS process.
- Sales protocol will be updated, signed and dated.
- Returned controlled drugs will be entered into the CD register.
- All sales to surgeries or dentist will be stopped.

30/09/2019 14/10/2019
2.4

There is insufficient reflection and learning from incidents to prevent them from happening again.

-Colleagues involved in clinically significant near misses and dispensing incidents to complete reflective statement and document and share learnings at huddles.
- Formal staff meetings will be carried out.

30/09/2019 14/10/2019
3.1

Not all areas of the pharmacy look professional.

-Ceiling tiles and damaged girder to be replaced
- A coloured basket system will be introduced to help with workload priority.

30/09/2019 14/10/2019
3.2

The facilities for private consultations are not sufficient to protect dignity and confidentiality.

-Ramp to be installed
-Window to be covered up
-Computer set to display screensaver after 5 seconds of inactivity

09/12/2019 14/10/2019
4.2

Not all the services are effectively managed to make sure that they are delivered safely.

-Additional colleague to learn MDS process.
-Delivery SOP to be reviewed and updated.
-All colleagues to reread and sign High Risk Medicines SOP.
-Sodium Valproate audit to be completed
-All colleagues to follow the same process for highlighting interactions and dose changes to the pharmacist
- The urgent repeat medicine service will be reviewed and only issued when the Surgery is closed.
- Staff have now got a process to highlight potential drug interactions

30/09/2019 14/10/2019