| 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 several risks associated with its services as failed under the relevant principles. The staff are not routinely working in line with all of the pharmacy's standard operating procedures. The pharmacy has no processes in place to ensure the safety of people prescribed higher-risk medicines and there are date-expired prescriptions present in the retrieval system that have not been identified as controlled drugs or processed in a timely manner |
All staff to reread and sign off all appropriate SOPs. Compliance to be checked by the management team. All relief and Locums to sign to say they have read and understood the RP SOPs on every visit Pharmacy to implement the company approved P2P process and additional storage requirements Store to find / order a copy of the updated Safeguarding policy and all staff to read, and sign to demonstrate understanding. Management to check knowledge. Store manager to complete contact sheet and display it conspicuously in the dispensary along with the process flow diagrams. Store to complete a full CD balance check and then maintain weekly. Any discrepancies to be full investigated and signed off by the management team. |
24/01/2020 | 27/04/2020 |
| 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 |
Safer Care champion to be identified and trained Training session to be carried out for all staff on safer care and near miss process, including what, and how to record near misses and how and when to review near misses, and the standards required for safer care. Management team to monitor weekly for a minimum of 8 weeks |
24/01/2020 | 27/04/2020 |
| 1.7 | The pharmacy is not routinely safeguarding people's confidential information. There is confidential information constantly left in an unlocked consultation room, the pharmacy does not inform people about how their private information is maintained, team members are sharing NHS smart cards to access electronic prescriptions and passwords are known |
Ensure all team members have their own NHS smartcard and password All materials containing patient sensitive information to be locked away in the consultation, or removed before the consultation room is left, every time the room is used. |
24/01/2020 | 27/04/2020 |
| 2.1 | The pharmacy does not have enough suitably qualified and skilled staff to provide its services safely and effectively. The current staffing arrangements are insufficient to cope with the workload, routine tasks are therefore not being completed or undertaken in a timely manner |
Staffing to be reviewed against Smartworks and any vacancies identified to be advertised. Right People, Right Place, Right Time scheduling model to be worked through and appropriate changes made Support to be given to store where appropriate facilitate holidays / sickness. |
24/01/2020 | 27/04/2020 |
| 3.1 | The pharmacy's services are not currently being provided in an environment that is appropriate for the provision of healthcare. The dispensary is extremely cluttered, untidy and disorganized and the pharmacy's workspaces are not kept clear enough to work safely on |
Dispensing areas to be cleared of clutter (main dispensary and CDS area) and designated areas identified for dispensing and checking. Area of shelving to be identified as an area to store Rx awaiting checking so they are not stored on the dispensary bench |
24/01/2020 | 27/04/2020 |
| 4.4 | The pharmacy is not making the appropriate checks in response to drug safety alerts. This means that they could supply medicines or medical devices that are not fit for purpose |
Store Manager to obtain copies of all drug alerts for the last 6 months, print them off and action them (even if actioned previously) then store them in a folder just for drug alerts. This must then be kept up to date and monitored by the CM |
24/01/2020 | 27/04/2020 |
Pharmacy inspections
Inspection reports and learning from inspections