| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not always adequately manage risks. Pharmacy team members work under pressure and don't always work in the safest way. And they do not fully complete some key tasks, such as properly managing medicines, which increases the risk of errors. |
Identify and address any staffing and capability issues by: (1) Reviewing the current staffing level against MaxE staffing model. (3) Provide support and induction for recently recruited colleagues. Review the rota for the next 6 weeks to ensure the pharmacy is appropriately supported throughout the week. Review all operational tasks in tasks at the pharmacy and ensure tasks are delegated appropriately to avoid disruptions when colleagues are involved in the dispensing activity. Implement a rota of suitable colleagues to complete weekly CD balance checks.
Report to Accountable Officer if any remain unresolved. Ensure all private prescriptions are recorded on the online Private Prescriptions register (CDRx). |
08/05/2024 | 07/05/2024 |
| 1.2 | Pharmacy team members do not record or fully discuss their mistakes. And they do not routinely make changes to help improve the quality and safety of services in response to the errors they make. |
Ensure all pharmacy team and regular pharmacists are aware of how to access and record near misses and PSI on Datix. The Field Manager to review the no. of near misses recorded by the pharmacy team during the weekly catch-up/ regular visits. Ensure all pharmacy team and regular pharmacists are aware of how to complete the monthly patient safety report. The Field Manager to review the content of the monthly patient safety report and ensure any learning from the near misses have been reviewed. |
08/05/2024 | 07/05/2024 |
| 2.1 | The pharmacy does not always have enough team members to safely provide its services. Team members work under pressure and do not complete all necessary tasks in a safe and timely manner. |
Identify and address any staffing and capability issues by: (1) Reviewing the current staffing level against MaxE staffing model. (2) Completing a Staffing and Capability Assessment to identify level of knowledge of Well Pharmacy processes. (3) Provide support and induction for recently recruited colleagues. Review the rota for the next 6 weeks to ensure the pharmacy is appropriately supported throughout the week.
Utilise support from experienced colleagues at nearby branch.
|
08/05/2024 | 07/05/2024 |
| 3.1 | The pharmacy is excessively cluttered and untidy. This increases the risk of team members making mistakes when dispensing people's medicines. And of team members tripping and falling while working. |
Arrange a cleaning and tidying-up session at the pharmacy. Improve medication storage by: |
08/05/2024 | 07/05/2024 |
| 4.3 | The pharmacy does not manage and store all its medicines as it should. It has inadequate date checking processes. It stores a significant number of medicines in crates rather than on the shelves. And team members do not store medicines transferred from original manufacturer's packs in a safe way. This increases the risk of errors. |
Date-check all medication in the pharmacy.
Ensure medication boxes are only containing medication with the appropriate batch no. and expiry. Ensure any white boxes with lose medication are labelled with the batch no. and expiry dates. |
08/05/2024 | 07/05/2024 |
Pharmacy inspections
Inspection reports and learning from inspections