| 1.1 |
Members of the team are unclear about some of the pharmacy's procedures and there is no evidence that they have read SOPs. |
The staff were shown the statement that the SOPs had been extended and were therefore reassured that the SOPs they had previously read and signed were the latest version.
Notwithstanding this, all pharmacy staff have now read the SOPs and signed them to declare that they have read and understood them to enable them to work safely and effectively.
The SOP file has been stored in an agreed and clear location in the ACT’s Office where there is now a clearly designated and organised area for record keeping and filing of all the
pharmacy’s procedures. This enables the staff to easily access the SOPs should they require to refer to them.
We have re-implemented a paper based near miss incidents log which all staff can see and have access to and have been trained on how to fill. The staff have all been directed to
report their mistakes on the log and the ACT, pharmacist and superintendent will ensure errors are logged, investigated and actioned as a team on a regular basis. This is now an expected procedure.
These changes were implemented within 5
days of the inspection being carried out. |
10/07/2023 |
23/06/2023 |
| 1.6 |
The CD records are inaccurate and unreliable. The responsible pharmacist record is incomplete. Unlicensed specials records are incomplete and disorganised. |
The Controlled Drugs Officer and
superintendent have outlined and
investigated any discrepancies and corrected them. Going forwards, clear accountability and a process of regular weekly checks on a Saturday of the running balance by the responsible pharmacist and the ACT have been implemented.
The staff have all been retrained on processes to ensure CD 2 prescriptions are signed out of
the CD register. For example, all CD 2
prescriptions must be attached to the bag containing the CD 2 medicine. When the CD 2 is handed out, the attached prescription must be handed to the responsible pharmacist or
ACT to sign the CD 2 out of the CD register.
The ACT has been trained on how to check the CD running balance and will do this every week. Any discrepancies will be investigated and actioned immediately with the assistance
of the responsible pharmacist. If the
discrepancy cannot be rectified, it will be reported to the superintendent who will investigate the discrepancy within one week of reporting.
All CD invoices will be filed in an organised manner as part of the new and improved filing and recording systems.
Reminder alerts have been placed on the PMR to remind the RP to log in and out of the RP log. These are set to go off 5 minutes after the pharmacy’s opening time and within 5 minutes of it’s closing time as an additional
measure. The RP log will also be checked on a daily basis to ensure the pharmacist has logged in and out the log.
The company has also alerted RPs who have not previously logged in and out and reminded them that it is a legal requirement to sign in and out of the log. They have also been retrained on how to do this on the PMR system. Furthermore – signs have been
placed on the checking bench to ensure the RP is reminded to log in and out of the register.
The ACT will now be accountable for ordering, recording and filing invoices for the unlicensed specials. We have allocated a more organised filing system for the unlicensed specials, and we have trained all staff members about keeping records of certificates of conformity with details of the
patient and date of supply (through sticking on a bag label). This re-emphasises a stringent culture of keeping a sound audit trail in the
event of queries or concern.
Methadone balances will be recorded on the Methameasure apparatus and will be checked, cleaned and calibrated on a daily basis by the pharmacist with the support of
the pharmacy team. |
10/07/2023 |
23/06/2023 |
| 2.3 |
There is a lack of professional leadership to provide assurance that the team is operating safely and effectively |
The superintendent has ensured that all staff now understand and work by legal and good practice procedures and record keeping as per the GPhC standards and company policies.
The ACT has been given a supervisory role and has been given the training, office space and authority to provide leadership and assurance that the pharmacy team is working within
operating standards and that legal
requirements are being met.
The superintendent will also visit the branch weekly to ensure that standards are being met and to support locum pharmacists, the
ACT and the pharmacy staff in running the pharmacy effectively, legally, clinically and safely.
The branch have valproate leaflets to give to patients and the staff have been trained on these and where these will be kept. Any further clinical leaflets or information resources will be filed in an easily accessible
and agreed location by the pharmacy staff.
Checks for stock medicines will be done every 3 months. There is a matrix on each medicine bay, and each member of the pharmacy team
has been given responsibility for a specific hub. The date of stock checking and the next date of checking will be recorded on the
matrix. The ACT will be in charge of ensuring stock checks are carried out and with diligence.
The ACT has been told that they must not accuracy check any prescriptions that have not been clinically checked. They must only accuracy check prescriptions which have been
initialed/signed by the pharmacist as having been clinically checked.
The staff have been retrained on recording the min/max temperatures of the fridge and have been trained on doing this daily on the PMR. Nevertheless, a fridge temperature
recording champion has been chosen who is now accountable for this task and must ensure it is completed daily. Compliance will be checked by the ACT and by the superintendent on their weekly shop visit.
There is a new filing cabinet for MHRA drug alerts. The staff have been trained to open drug alerts, print them off, action them and then sign the alert as being completed with a
date and signature. This alert will then be recorded in the designated filing cabinet in the ACT’s office. |
10/07/2023 |
23/06/2023 |
| 4.3 |
Controlled drugs are not always stored appropriately. |
The CD cupboard has been moved to an alternative location (away from patients) where it has been bolted in place to a wall and cannot be moved freely as per British Security Standards (secured to a wall and fixed with bolts that are not accessible from outside the cupboard, fitted with a robust
lock, made of metal with strong hinges).
Stock levels of CDs will be closely monitored.
The pharmacy has several buprenorphine patients and as there had been an issue in getting buprenorphine tablets, the pharmacy
had ordered extra tablets to keep in stock.
The CD cupboard has since been tidied and stock levels will gradually go down as medicines are used up and specific CDs are not ordered. |
10/07/2023 |
23/06/2023 |
