| 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. The pharmacy team could not locate the company's standard operating procedures (SOPs) at the point of inspection. There is no evidence that all of the current team has read the pharmacy's SOPs. The staff are not routinely working in line with all of the pharmacy's SOPs. And there is evidence that things have gone wrong because of this. |
Complete copy of current SOPs to be available in the pharmacy with all colleagues aware of the location All colleagues to read and complete the RoC for all SOPs relevant to their role including MyLearn records. All colleagues to be signed off by the Pharmacy Manager as understanding and following SOPs |
14/06/2022 | 15/06/2022 |
| 1.2 | The pharmacy does not have a robust process in place to manage and learn from incidents. Staff are not routinely recording details about incidents, complaints or near misses, they are not completing their company's internal Safer Care processes and there is no evidence of remedial activity or learning occurring in response to mistakes. |
SaferCare briefing to be held to discuss report with all team members SaferCare training to be held with pharmacy team to ensure they are fully aware of what is required including reporting of incidents and complaints as per professional and company guidelines SaferCare processes to be recommenced within the pharmacy with immediate effect Near Miss training to be held with the team to ensure they are all fully aware of what is required Near Miss recording to be recommenced with immediate effect Training to be held with the team on how to report any incidents or complaints on the company systems Actions and learnings from incidents or near misses to be discussed and documented as per company guidelines Near miss review to commence every month in line with company guidelines and all team members briefed All CD discrepancies to be reviewed and investigated in line with company processes |
14/06/2022 | 15/06/2022 |
| 1.6 | The pharmacy has not been keeping and maintaining all the necessary records for the safe provision of pharmacy services. |
Fridge temperatures to be recorded every day in the morning as per Dispensary SOPs
|
14/06/2022 | 15/06/2022 |
| 1.8 | The pharmacy has evidently failed to appropriately safeguard the welfare of vulnerable people. They have not always ensured that people receive the correct medicine(s) in a timely manner or within multi-compliance packs. And there is evidence that mistakes have happened because of the lack of staff, inadequate staff training and due to the chaotic manner in which the team is having to work. |
Safeguarding training to be held with the team to ensure all colleagues are fully aware of their role and responsibilities. All colleagues to have read and understood the Safeguarding policy and completed the RoC Local Safeguarding Details template to be completed and displayed within the pharmacy along with Emergency Out of Hours guidance process flow Actively recruit new colleagues and provide support from colleagues in neighbouring pharmacies (as appropriate) to ensure the pharmacy have adequate colleague levels to manage their workload safely and effectively and to clear any backlog of work. Full review of dispensing processes and workflow alongside staffing profile across opening hours to ensure the appropriate colleagues are in at the right place at the right time to manage the workload effectively. |
14/06/2022 | 15/06/2022 |
| 2.1 | The pharmacy does not have enough suitably qualified and skilled staff to provide its services safely and effectively. The current staffing arrangements are insufficient to cope with the workload, the team is significantly behind and routine tasks are not being completed or undertaken in a timely manner. |
Actively recruit new colleagues and provide support from colleagues in neighbouring pharmacies (as appropriate) to ensure the pharmacy have adequate colleague levels to manage their workload safely and effectively and to clear any backlog of work. Review of staffing profile to highlight potential gaps and ensure adequate cover across opening hours of branch. Once review completed, a colleague rota to be created. |
14/06/2022 | 15/06/2022 |
| 2.5 | The pharmacy’s management has not taken appropriate action when the pharmacy team members raise legitimate concerns about their working environment and training needs. And any action they did take was inadequate. So members of the pharmacy team remain inadequately supported, and under-resourced. This means that they cannot effectively manage the safe operation of the pharmacy. |
Actively recruit new colleagues and provide support from colleagues in neighbouring pharmacies (as appropriate) to ensure the pharmacy have adequate colleague levels to manage their workload safely and effectively and to clear any backlog of work. Review of staffing profile to highlight potential gaps and ensure adequate cover across opening hours of branch. Once review completed, a colleague rota to be created. RM to speak with PM on a weekly basis to discuss any concerns and escalate as needed to DQM and HoD. |
14/06/2022 | 15/06/2022 |
| 3.1 | The pharmacy's services are not currently being provided in an environment that is appropriate for the provision of healthcare. The dispensary is cluttered, untidy and disorganized, the pharmacy's workspaces are not kept clear enough to safely work on, and parts of the premises have significant piles of rubbish or returned medicines which have not been cleared effectively. In addition, there are health and safety risks such as the risk of tripping on poorly maintained stairs, which have not been addressed, fixed or highlighted appropriately. |
Full clean, tidy and declutter of the pharmacy premises including clearing the dispensary benches Remove build-up of rubbish and waste medicines and ensure this is actioned regularly going forward. Review any health and safety risks and ensure outstanding maintenance issues (including the stairs) are actioned. |
14/06/2022 | 15/06/2022 |
| 3.3 | The pharmacy's premises are not maintained to a level of hygiene appropriate for the services it provides. Some parts of the pharmacy are dirty. The pharmacy is not being cleaned regularly. This includes the toilets. |
Full deep clean of the pharmacy premises including staff areas to be completed.
|
14/06/2022 | 15/06/2022 |
| 4.1 | The pharmacy's services are currently insufficiently accessible to patients and the public. The pharmacy is not routinely allowing people freely into its premises and closing every afternoon. It is not providing its usual repeat prescription service or the delivery service on time for people who have signed up for them because it does not have enough staff. This means that people are unable to easily access their medicines. |
Review of staffing profile to highlight potential gaps and ensure adequate cover and access for patients across full opening hours of branch. Review of repeat prescription services and delivery services to ensure patients are receiving medication as appropriate. |
14/06/2022 | 15/06/2022 |
| 4.2 | The pharmacy's services are not managed or delivered safely and effectively. There are risks associated with the preparation and assembly of multi-compartment compliance packs and there is evidence that mistakes have subsequently happened. |
All colleagues to read and sign the CDS SOP and guidance documents to confirm their understanding and ensure correct processes are implemented and followed for the dispensing of CDS trays. Review of CDs patients to ensure all records are accurate including when they are due. Review of repeat prescription services and delivery services to ensure patients are receiving medication as appropriate. |
14/06/2022 | 15/06/2022 |
| 4.3 | 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 large quantities of 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. |
Dispensary to receive a full date check with any out-of-date medicines removed and short dated stock highlighted Date checking schedule to be carried out as per company policy. Training held with the pharmacy team on fridge temperature recording including reading and understanding the fridge temperature SOP Fridge temperatures to be recorded every day in the morning as per Dispensary SOPs |
14/06/2022 | 15/06/2022 |
| 4.4 | The pharmacy cannot demonstrate that it has appropriate procedures in place to raise concerns when medicines or medical devices are not fit for purpose. The pharmacy team has not been dealing with and appropriately acting upon the drug alerts issued by the Medicines and Healthcare products Regulatory Agency. |
Training to be held with the team to review the company recall and alert processes to ensure they understand what is expected Any recalls and alerts are identified in a timely manner and processed accordingly |
14/06/2022 | 15/06/2022 |
Pharmacy inspections
Inspection reports and learning from inspections