| 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. Staff are not routinely working in line with all of the pharmacy's standard operating procedures (SOPs). And there is evidence that things have gone wrong because of this. |
To identify risk areas and for all staff to read and strictly follow standard operating procedures at all times. Staff to be encouraged to ask about any procedures if unsure of anything. This will help to reduce chances of errors. |
22/11/2024 | 08/11/2024 |
| 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. And there is little to no evidence that appropriate remedial activity is taken or learning occurs in response to mistakes. |
All staff to read and understand SOPs on incident recording and reporting. Team meeting to be arranged to discuss the importance of incident reporting and learning outomes. Regular near miss patterns to be identified and discussed with the team, appropriate measures to then be implemented to limit any further dispensing errors (i.e. LASA drugs) Previous dispensing errors to be recorded/logged and relevant GPHC communication to be attached. Records to be kept in file in branch. Interventions to be recorded on patients PMR and error to be discussed with staff and complete a root cause analysis to identify the cause and prevent future occurrence. Complaint procedure poster to be moved to a more prominent area so it is more visible. |
22/11/2024 | 08/11/2024 |
| 1.7 | The pharmacy does not sufficiently protect the privacy, dignity and confidentiality of people who use the pharmacy's services. |
During the inspection it was bought to our attention that patient data may be visible in two different locations, in front of the consultation room and bagged medication in top draw of retrieval system. Action already has been taken to resolve this issue: * Dispensary area is no longer visible from consultation room - Preventing visibility of patients details on medication packs/prescriptions All staff have been briefed on the importance of handling patient data and to adhere to strict regulations when dealing with circumstances that involve such, whether it is verbal or in writing. On the GPHC visit, the inspector noticed that the vaccinator was not fully complying with basic data protection - highlighted to the team during the visit. Since then we decided to seek a new vaccinator who has read through and complies with SOP's, data protection and approaches tasks at hand with professionalism. |
22/11/2024 | 08/11/2024 |
| 3.2 | The pharmacy's facilities for private and confidential conversations and services are not sufficient |
Signs are now in place to highlight the consultation area and a staff discussion has taken place to highlight the importance of offering patients a chance to discuss their matters inside this room. All patients requiring consultations/advice, where possible, are now asked to talk in private within our consultation room. This will prevent conversations on the shop floor. Due to a Lloyds branch in taplow closing down, and the local Lloyds within the local surgery changing hands, we have noticed a considerable increase in patients. We have made imminent plans for a refit, to increase in the size of the dispensary and to provide a more suitable consultation area, all of which we believe will help provide better care for our patients. |
22/11/2024 | 08/11/2024 |
| 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. There is limited evidence to verify that the pharmacy team has been dealing with and appropriately acting upon the drug alerts issued by the Medicines and Healthcare products Regulatory Agency. |
Team meeting to discuss the importance of medication drug alerts and the procedure to undertake when a drug alert is received. Are ensuring drug alerts are being sent to branch email and a separate folder to be made containing all drug alerts received and to be marked appropriately to show that it has been checked against stock held in the pharmacy. |
22/11/2024 | 08/11/2024 |
| 4.2 | The pharmacy's services are not managed or delivered safely and effectively. There are risks associated with the delivery service and the preparation and assembly of multi-compartment compliance packs. And there is evidence that mistakes have subsequently happened. |
Delivery drivers have now read and understand importance of adhering to SOPs in order to prevent incidents that have occured. We have already highlighted the importance of safe delivery of medication - All undelivered medication to be bought back to the pharmacy until patient notifies pharmacy for collection or re-delivery. An area is to be set aside for compliance packs and patient information leaflets to be provided with all blister packs. Team meeting to discuss the importance of safe and effective dispensing of blister packs. Stock for blister packs to be picked before dispensing, ensuring complete quantities are present to ensure blister pack is not left unsealed overnight. Cleaning rota to be put in place to help maintain tidiness of dispensary. All shelves to organised and removal of any medication not in original pack. |
22/11/2024 | 08/11/2024 |
Pharmacy inspections
Inspection reports and learning from inspections