| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy is not following its established procedures to assess, review or monitor the safety and quality of the pharmacy's services. The company's internal 'Safer Care' processes have not been fully completed and there is limited evidence of review, remedial activity or learning occurring in response to mistakes. |
SaferCare champion to be identified and trained who will oversee SaferCare at the pharmacy. 3-month review of both SaferCare and Near Miss to be completed and one off SaferCare briefing to be held with the team and documented. |
20/07/2022 | 20/07/2022 |
| 1.1 | The pharmacy is not identifying and managing several risks associated with its services as indicated under the relevant failed standards and Principles below. |
All team members to be retrained on Safeguarding policy and contact details to be updated. CD balances to be completed weekly in line with company processes and complete list of discrepancies to be supplied to DQM for investigation. Obsolete / OOD schedule 2 CDs to be destroyed in presence of Authorised Witness. Patient returns / schedule 3 and 4 CDs to be destroyed. CD key log to be printed off and completed daily before keys are handed to a Pharmacist. All colleagues to be retrained on High Risk Medicines SOPs and the appropriate use of stickers to be monitored by RM All colleagues to be retrained on fridge temperature process and process to be completed daily. RP log to be completed electronically via internet explorer daily. |
20/07/2022 | 20/07/2022 |
| 2.1 | The pharmacy does not have any of its own suitably qualified and skilled staff to provide its services safely and effectively. The current staffing arrangements are completely reliant upon staff from the company's surrounding pharmacies. This situation is unsustainable long-term, and not all routine tasks are being completed or undertaken in a timely manner. |
Ongoing recruitment for qualified and non-qualified colleagues including: Rota to be drawn up for the next 6 weeks indicating colleagues to be working in branch by day to ensure no lack of coverage. People review to be completed when all colleagues have been recruited to ensure no lack of coverage. |
03/08/2022 | 20/07/2022 |
| 3.1 | The pharmacy's services are not fully being provided in an environment that is appropriate for the provision of healthcare. Parts of the premises are cluttered, require cleaning with health and safety risks from the poorly maintained stairs. |
Deep clean for the pharmacy to be organised.
Damaged steps to be reported to maintenance and repaired. In the interim, highlight broken steps with yellow hazard tape |
20/07/2022 | 20/07/2022 |
| 4.4 | The pharmacy cannot demonstrate that it has appropriate procedures in place to raise concerns when medicines or medical devices are not fit for purpose. There is no evidence that the pharmacy team has been dealing with and appropriately acting upon the drug alerts issued by the Medicines and Healthcare products Regulatory Agency. |
All colleagues to be trained in how to access the HuB to demonstrate compliance with company recalls and alerts procedures. All drug alerts and recalls to be reviewed for the last 6 months to ensure all have been completed |
20/07/2022 | 20/07/2022 |
| 4.3 | The pharmacy is not managing its medicines in a satisfactory way. This compromises the safe supply of medicines and medical devices. The team has not consistently been checking medicines for expiry. Short-dated medicines are not identified and the staff cannot show that they have been storing medicines requiring refrigeration at the appropriate temperatures. |
Complete date checking cycle to be completed in the dispensary and store, after which company cycle to be maintained weekly. All colleagues to be trained on how to complete the fridge temperature checking process and this is then to be completed and recorded every morning. |
20/07/2022 | 20/07/2022 |
| 4.2 | The pharmacy's services are not always managed or delivered safely and effectively. The pharmacy has not kept appropriate audit trails to verify that it has been following its processes for the delivery service. And, the pharmacy has no processes in place to ensure the safety of people prescribed higher-risk medicines. |
A copy of all deliveries should be kept by attaching a bag label to a piece of paper to check against in the event of queries. These additional records should be kept for 7 days All colleagues to be aware of how to access EPOD logs direct from the centre in the event of a query. |
20/07/2022 | 20/07/2022 |
Pharmacy inspections
Inspection reports and learning from inspections