| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy is not following many of its own procedures and as a result is not adequately assessing or managing the key risks to patient safety. |
A safer care champion is to be nominated for the store, then all relevant store colleagues to be trained on the safer care process, and the weekly tasks to be restarted. One complete cycle to be reviewed initially to get an overview of where the store is currently. |
19/11/2019 | 26/11/2019 |
| 1.2 | The pharmacy does not keep adequate records of the mistakes it makes, and it does not review or learn from them. |
All relevant team members to be trained on the near miss process, including training to support on Root Cause analysis, Reflective Statements and the 5 Whys document. Training to be given to the store manager and pharmacist on how to review near miss logs monthly as part of the safer care process. |
19/11/2019 | 26/11/2019 |
| 1.6 | The pharmacy’s records for assuring the safety of its services are inadequate and incomplete. |
All relevant team members to be retrained on the fridge temperature recording SOP and the need to record the max/min/current temps daily All relevant team members to be retrained on the recording requirements for Specials. |
19/11/2019 | 26/11/2019 |
| 2.1 | The pharmacy does not have enough staff members to deliver the workload in a safe and effective manner. |
Please review the current staffing levels against the company staffing profile tool and support accordingly where there may be a deficit. Please complete the company Right Person Right Place Right Time tool to ensure there is an adequate coverage of staff during the working day. |
19/11/2019 | 26/11/2019 |
| 4.3 | The pharmacy cannot provide sufficient assurance that all of its medicines are safe for people to take. The pharmacy is not recording the fridge temperatures on a daily basis and does not have the most up to date drug alerts from the MHRA. |
All relevant team members to be retrained on the fridge temperature recording SOP and the need to record the max/min/current temps daily and what to do if the temperature is outside of the normal range. A full list of recent (6 months) MHRA alerts to be collated and all stock checked. All team members to be retrained on MHRA process and how to store alerts. |
19/11/2019 | 26/11/2019 |
Pharmacy inspections
Inspection reports and learning from inspections