A.F.Norman Chemists Ltd. (1030221) - Improvement action plan

The pharmacy has some medicines which have to be kept in secure storage. But it does not always store them securely. And Controlled drugs aren't stored in accordance with safe custody requirements. The pharmacy can’t demonstrate that it always stores all its temperature-sensitive medicines within the right temperature

All CDs that are stock are at all times stored safely and securely in accordance with all criteria. Cabinets are secure, clean, in multiple locations to separate stock types, and all keys are double secured in locked storage already, but it will all be looked at again to see if there is any way to ensure continual improvement is possible. The fridge temperature recording is being made everyones job to do rather than just the pharmacists, with records on old fashioned always accessible paper rather than the complicated electronic record keeping that has always been lacking in its reliability.

The pharmacy does not demonstrate how it manages all the risks for providing its services. Written procedures available to its team members do not include core information about the responsible pharmacist's (RP's) role. And not all team members know what tasks they can do in the RP’s absence. This creates a risk of team members not working in accordance with regulatory requirements.

The RP SOP has been replaced with the current one provided by Numark which meets all the criteria of the GPhC. The previous SOPs were provided by Alphega and were electronic accessed through a tablet in the pharmacy but leaving the Alphega organisation led to this being inaccessible. Paper copes are available and signed by the staff now.

The pharmacy does not always make sure its records are comprehensive and up to date. For example the responsible pharmacist record was unavailable during the inspection. So it is not clear the records are made contemporaneously. Additionally, the pharmacy does not always make records about medicines people have returned that require secure storage. Or fill in all the required details when it makes a supply or receives these medicines. This means that team members may not be able to check records if there are any future queries.

Will ensure that more staff than just myself know about the location of the RP log to ensure that on the days a locum is here someone know what to do to access this information. We have all necessary records available for returned CDs, all staff actively ask if bin bags of returned medication have sharps of CDs in them before accepting them, so that they can be processed differently.