Wendover Pharmacy (1029074) - Improvement action plan

The pharmacy is not routinely identifying and appropriately managing some risks associated with its services as indicated under the relevant failed standards and Principles below. There is evidence that things have gone wrong because of this.

All colleagues to work through all Standard Operating Procedures and associated guidance relevant to their role and sign the relevant record of competences to confirm understanding.

All colleagues to read the Safeguarding Policy and sign to confirm their understanding.

Methadone balance checks and overage calculations to be carried out weekly in line with the CD Standard Operating Procedures.

Colleagues to be trained on SaferCare process and on the near miss process. All near misses to be recorded in full in line with company guidance.

SaferCare to be completed weekly as per company process.

Near misses and patient safety incidents to be reviewed as part of monthly SaferCare process and shared with all colleagues in a SaferCare briefing to support learning and implement actions as identified

The pharmacy has compromised the safety of medicines and medical devices due to inadequate management of its medicines. The team has not consistently been checking medicines for expiry. The pharmacy has some date-expired medicines in amongst its stock, short-dated medicines are not identified and the staff cannot show that they have been storing medicines requiring refrigeration at the appropriate temperatures.

The dispensary stock, stock room area and shop floor to be date checked. All short-dated stock to be highlighted, and out of date/obsolete medication disposed of in an appropriate manner.

Date checking matrix to be set up and maintained following company process going forward.

All prescriptions that have a 28 day expiry (including Schedule 4 CDs) to be highlighted to ensure this can be identified prior to prescription handout.

All high-risk medicines must be highlighted and managed as per company SOPs.