| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not adequately identify and address the risks for the services it provides. Pharmacy team members do not always follow the pharmacy's written procedures and they do not always follow safe working practices. |
Identify and address any staffing and capability issues by: Consider recruiting an accuracy checker. Currently recruiting a pharmacist. Consider recruiting Pharmacist Branch Manager. Prioritise this with bi-weekly calls with recruitment team. Block book locum who is familiar with Well processes. Consider moving a Well pharmacist from R12 to support. Complete GPhC fishbone. Area Operation Manager to visit the pharmacy weekly, supported by Regional Operation Manager. Consider and arrange an out of hours training session for the colleagues. Organise and tidy-up the dispensary shelves. Date check all stock in the dispensary and establish a date checking rota. Reduction of stock holding at the pharmacy. Review the stock ordering process and share with the pharmacy team. |
07/05/2024 | 09/05/2024 |
| 1.2 | The pharmacy does not promote an open culture of learning from mistakes. Pharmacy team members cannot demonstrate adequate learning from these types of events. |
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. |
07/05/2024 | 09/05/2024 |
| 2.2 | Pharmacy team members have not completed adequate training associated with the pharmacy's processes. And one team member has not been enrolled on a GPhC accredited training course within the time frame required. |
Hold a Patient Safety Huddle to discuss the following: - Importance of adhering to the core dispensing SOP (Ensure all colleagues read SOP 1-8) Ensure colleagues are on-track with their Buttercups training. Enrol new colleague(s) on the relevant Buttercups course. |
07/05/2024 | 09/05/2024 |
| 4.2 | The pharmacy’s intermittent internet connectivity is causing a backlog of work and is comprising the team’s ability to manage the pharmacy’s dispensing services safely. The placement of the pharmacy's automated collection point on registered premises means people can collect their medicine from the pharmacy when a responsible pharmacist is not present. |
Share SOP and RA with pharmacy team leader and the team. Review the SOP to include what to do if the temp inside the machine is above ambient temperature. Contact Medpoint and upgrade the machine/ Upgrade the fan to improve ventilation. De-register the premises where the machine is located. Define the end-to-end process of the use of the collection point machine. |
07/05/2024 | 29/08/2024 |
| 4.4 | The pharmacy does not suitably respond to concerns about the safety of medicines and medical devices, such as drug recalls. |
Ensure all colleagues understand the drug recall process - read SOP 18 Stock Management. |
07/05/2024 | 09/05/2024 |
| 5.1 | The pharmacy’s intermittent internet activity compromises the safe and effective delivery of its services. |
BT engineer has visited and has installed a new line. Moved phone lines from the internet. Report any IT issues to the IT team. |
07/05/2024 | 29/08/2024 |
Pharmacy inspections
Inspection reports and learning from inspections