Badham Pharmacy Ltd (1031484) - Improvement action plan

The pharmacy is not identifying and managing several risks associated with its services as indicated under the relevant failed standards and Principles below. The pharmacy team 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. This is creating significant risks.

All staff have read the SOP’s.
All of the staff have signed the SOP’s
A hard copy of the SOP’s is held in the branch in addition to the online version. A staff meeting was held which discussed the importance of following the SOP’s.
All staff are complaint with the SOP’s

The pharmacy records for assuring the safety of services are
incomplete, inaccurate, or not available. All necessary records to verify that pharmacy services are provided safely should be readily available for inspection. At the point of inspection, the pharmacy was unable to provide records to verify that it had been recording fridge temperatures regularly. And the pharmacy has consistently failed to ensure details within other necessary records required for the safe provision of pharmacy services are kept in accordance with legal requirements.

The fridges have data logger thermometers that record the temperatures back to an iPad. Historical data can be reviewed through the app.
The Private Prescription file has been checked and any missing data has been added so the files are complete and correct.
The Pharmacy First PGD’s have been printed and signed by the RP’s at the branch.
Each clinical pathway has its own folder which contains the PGD’s for ease of reference during a consultation.
The Flu and COVID PGD’s have been printed , read and signed off and are held in a folder.

There are no audit trails in place for the pharmacy to identify who was responsible for professional
activities such as clinical checks made or accuracy checking when this has been undertaken by a non-pharmacist accuracy-checker.

An ACT stamp has been obtained that records who has undertaken the clinical check, who had dispensed the prescription and who has completed the accuracy check.
The dosette boxes have an audit sheet that records who has ordered the prescription , when the prescription arrived , who picked the stock, who made the tray , who carried out the accuracy check , who carried out the clinical check.

The pharmacy does not have a culture of openness, honesty and learning. There are gaps in the team's knowledge. And no evidence that regular updates are shared with the team, or resources provided to help them with ongoing learning.

The branch has been set Virtual Outcome modules to cover. HR have the ability to check these modules are being accessed and that team members are adhering to the schedule.

Drug recalls and all other information provided by NHS England, or the SI are being printed off, read by the team, signed and retained in a folder. This important process is being controlled by one of the dispensing staff.

The pharmacy has compromised the safety of medicines and medical devices due to inadequate management of its medicines. The team has not consistently been checking medicines for expiry. The pharmacy has large quantities of date-expired medicines in amongst its stock, short-dated medicines are not always identified and the staff cannot show that they have been storing medicines requiring refrigeration at the appropriate temperatures.

The pharmacy has been completely date checked.
The ongoing control of this process will be lead by one member of staff to ensure compliance looking forward.

The Fridge temperatures are being recorded to a iPad to review and monitor temperatures are in the range 2-8.