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Pharmacy inspections

Inspection reports and learning from inspections

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Western Elms Pharmacy (1028990) - 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 not identifying and managing several risks associated with its services as indicated under the relevant failed standards and Principles below. There is no evidence that the team has read and understand the pharmacy's standard operating procedures. The pharmacy has not been managing its COVID-19 vaccination service safely or in line with the appropriate operating procedures and legal mechanisms. And it has inadequate systems in place to help prevent the spread of infection from COVID-19.

The pharmacy has requested for a closure for the COVID vaccination clinic at Western Elms.
Staff meeting has taken place with the superintendent pharmacist, Deputy Superintendent pharmacist, Group operations manager and the Area manager.

All members of the pharmacy team had read and understood the company SOPs (this
has been checked with the staff on site), however signature sheets were not signed at
the point of the inspection which is acknowledged and has since been actioned. The
Superintendent pharmacist was not notified by the RP and the manager on there being
any issues for why the signature sheets have not been signed. Staff have been spoken to
and have been informed on the requirement of ensuring all SOPs and processes are
read, understood and signed. There has been regular interaction with the branch by the
Group operations manager, Area manager, Relief pharmacists and the SI pharmacist –
during this time any deviation from company protocols were not identified or
communicated by the regular RP/Manager.

14/09/2021 31/08/2021
1.6

All necessary records to verify that pharmacy services are provided safely should be readily available for inspection. The pharmacy has been unable to demonstrate that it has been keeping all the records it requires to prove this. At the point of inspection, the pharmacy was unable to locate any records to verify that it had been recording supplies of unlicensed medicines as required by law. And, there were no records available about the COVID-19 vaccination service.

Staff members have all been spoken to and are now familiar with the locations of relevant documents. Specials records are available and stored in the specials folder located in the dispensary.
Records for the COVID-19 vaccination service (available on the branch shared access folder) have now been printed and kept in a folder at the branch.

14/09/2021 31/08/2021
1.7

The pharmacy is not protecting the privacy, dignity and confidentiality of patients and the public who receive its services. The pharmacy has been inappropriately storing and leaving confidential information in the retail space for people using the pharmacy's COVID-19 vaccination service. Team members frequently share each other's passwords and there were no information governance processes seen.

All members of the team have been briefed on Information Governance requirements. IG SOPS have been read and understood by staff working at the branch including pharmacists and any locum pharmacists.
All members have been briefed on the need to use their own smartcards at all times. Plans will be put into place, for 1 member to work on a designated terminal and NOT to share terminals where possible. When leaving the terminal, the smartcard must be removed.

14/09/2021 31/08/2021
1.2

The safety and quality of the pharmacy's services are not regularly reviewed and monitored. The pharmacy is unable to fully demonstrate that it records all its mistakes, monitors and informs others or learns from them.

Audits do take place on a regular basis. Majority of the outcomes are based on patient feedback, lead clinician input and adapts processes accordingly. The COVID vaccination service has been terminated.

14/09/2021 31/08/2021
2.4

The pharmacy does not have a culture of openness, honesty and learning. The pharmacy has no independent whistleblowing process in place where the team can feel comfortable to raise concerns. And there are no resources provided to the staff to help keep their skills and knowledge current.

There is a whistleblowing policy in place in the staff handbook. All members of the team are aware of this.
Staff have completed their annual appraisal where concerns can be raised.
Resources are in place to help staff keep up to date with their skills and knowledge. Communication is sent from Head Office at regular intervals. Superintendent pharmacist’s team has requested for all members of the team to complete a training record to evidence training and upskilling undertaken.

14/09/2021 31/08/2021
2.5

Members of the pharmacy team are not empowered to provide feedback and raise concerns about meeting the GPhC's standards and other aspects of the pharmacy services. Staff are reluctant and fearful to raise issues in front of management or to discuss concerns for fear of losing their jobs. A culture of fear exists.

A meeting has taken place with all members of the team to discuss plans on channels of communication. Staff have also been encouraged to contact colleagues from other branches if they wish to discuss any issues prior to speaking to a member of the management team. Staff are aware of their point of contact in the absence of their manager. This will include their Area Manager, Deputy Superintendent pharmacist, Group operations manager, Superintendent pharmacist.

14/09/2021 31/08/2021
3.1

The pharmacy's services are not provided from an environment that is appropriate for the provision of healthcare services. The pharmacy is unclean and it is cluttered. This includes the storage areas and part of the retail space. There is evidence that the pharmacy is risking unauthorised access to medicines and needlestick injury from how it is currently storing used sharps and medicines returned by the public for destruction.

The Pharmacy has ceased to provide the COVID vaccinations service. Visits from the CCG and infection control team have taken place. Reports sent to GPHC inspector. The reports suggest that the pharmacy environment is appropriate for the provision of healthcare services.
A Meeting has taken place with members of the team on the importance of maintaining hygiene standards at all times. If staff are not able to comply with the cleaning requirements, then the Superintendent pharmacist’s team must be notified promptly. The used sharps and returned medicines seen at the point of inspection have changed their storage space. The pharmacy has not had any incidents of unauthorised access to this area, as it is manned by a member at all times.

14/09/2021 31/08/2021
3.3

The pharmacy's premises are not maintained to a level of hygiene appropriate to the services it provides. The pharmacy is dirty. It is not being cleaned regularly. This includes the toilets and the handwashing facilities. And the pharmacy's processes to keep people safe from infection during and after having their COVID-19 vaccination are inadequate.

A deep clean of the premises has taken place.
An external cleaner has been appointed. Staff have been explained on the importance of maintenance of hygiene and cleanliness in their area of work at all times. Staff have been asked to re-visit the company COVID measures document and guidance. Any deviations must be reported to the superintendent pharmacists team promptly.

14/09/2021 31/08/2021
4.4

The pharmacy cannot fully verify that it has the appropriate procedures in place to raise concerns when medicines or medical devices are not fit for purpose. The pharmacy is not always opening emails about the drug alerts issued by the Medicines and Healthcare products Regulatory Agency. And it cannot demonstrate that it has actioned the drug alerts appropriately.

All members of the team have been asked to read the SOP on Drug alerts and Recalls.
The site has been sent a link to accessing alerts and recalls which has been saved onto the pharmacy computer terminals.
Alerts and Recalls are sent via NHSmail to the branch, these e-mails need to be accessed daily. This has been placed as a daily task for the branch. Head Office also send communication on Recalls and Alerts.
Compliance on this will be monitored on a monthly basis by the Superintendent pharmacist’s team.

14/09/2021 31/08/2021