| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy is not identifying and managing some risks associated with its services as failed under the relevant standards and Principles. In addition, staff are not acting in a suitable manner to routinely protect people's private information. Private prescriptions are not stored securely, staff areas are unclean, there is no schedule to verify that medicines have been routinely checked for expiry and no records of calibration have been maintained for the blood glucose testing service |
Date checking matrix is now back in place in Pharmacy. All items which had been on the matrix previously have been checked to bring the branch up to current weekly cycle to minimise any potential risk. Private prescriptions (Rx’s) are stored in Private Rx folder, which is stored within the dispensary shelving unit. All team members are aware they are not to leave any Rx’s in the Private Rx book. Cleaning Rota has been implemented with a ‘cleaned by’ section to ensure compliance and any necessary follow up. New blood glucose meter calibrated & matrix is in place which is stored with the glucose meter. Will be routinely checked as per Safer Care requirements. |
02/12/2019 | 18/11/2019 |
| 1.2 | There is not enough assurance that the pharmacy has a robust process in place to manage and learn from dispensing incidents. Staff are not routinely recording near misses, they are not completing their company's internal Safer Care processes and there is no evidence of remedial activity or learning occurring in response to mistakes |
Post GPhC visit briefing completed by branch manager to all team members to ensure they are aware of all feedback and learnings from inspection. Safer care briefing held to help team further understand Route Cause Analysis & Reflective Statements in line with Safer care with particular usage around PAS onboarding. Near misses are now being completed by team following briefing, notation will be made if there are no ‘near misses’ on that date. Pharmacists are shown Near Miss log and where it is located each day to ensure it is completed by team. Designated Safer care Champion will be ensuring Near Miss review will be completed |
02/12/2019 | 18/11/2019 |
| 4.2 | Pharmacy services are not managed or delivered safely and effectively. The pharmacy has not kept appropriate audit trails to verify processes for some of its services. This includes the delivery service and repeat prescription collection service. And, the pharmacy has no processes in place to ensure the safety of people prescribed higher-risk medicines |
Patient deliveries are detailed in daily diary for all current and future deliveries. Duplicate pad used for repeat prescription orders which are sent to the surgery. Duplicate pad then followed up in a timely manner to ensure prescription request is fulfilled. All Rx’s checked in PCS collection box & stickers placed on relevant bags for ‘high risk medicines’. All team aware that Rx to be highlighted when dispensing/being checked that it is to be flagged if High Risk Medication included. Methotrexate High Risk Audit also being completed currently. All team briefed and signed briefing. |
02/12/2019 | 18/11/2019 |
| 4.3 | The pharmacy cannot verify that it has been storing medicines that require refrigeration at the appropriate temperatures |
Fridge SOP’s have been re-signed by all Pharmacy teams and a Fridge Temperature Control Check form is on the front of fridge. Duty has been delegated to a member of staff to complete daily and a second person in their absence. |
02/12/2019 | 18/11/2019 |
Pharmacy inspections
Inspection reports and learning from inspections