| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not assess and manage the risks associated with several key processes. And it does not regularly review its written procedures. The pharmacy does not have procedures covering all its professional services. And, not all pharmacy team members follow the procedures available. |
I intend for all SOP’s to be reviewed and the process is now in place and will be completed by 1st April 2020. There will also be included an SOP on safeguarding. All staff have read the current SOP’s and are contributing to the review process. Any procedures that become apparent that are missing with in the review process will be put in place. The team are aware of how important the SOP’s are and this will be reenforced in the annual appraisal. |
20/02/2020 | 22/04/2020 |
| 1.2 | Pharmacy team members do not record near miss errors that happen whilst dispensing. They cannot evidence any records they make of dispensing errors as they cannot easily retrieve them. And, they only occasionally discuss or make changes to help prevent mistakes happening again. |
Written warning now in place for anyone not following the Final check protocol that has been in place for a number of years. All near misses are recored and the reason for the the near miss analysed and discussed with the responsible pharmacist who will then sign off the error recorded before the log is filed. Error/near miss data will be discussed at the annual appraisal. All errors will be analysed continually as the pharmacist will be signing off each one. An overall review will be done six monthly and all errors analysed and this review will be documented in the error log folder. |
20/02/2020 | 22/04/2020 |
| 4.2 | The pharmacy does not effectively manage all of its services. For example, the pharmacy doesn’t have adequate controls in place during the dispensing and checking process. And, the pharmacy doesn’t have reliable audit trails for some of its services. This includes for the medicines it delivers to people’s homes. The pharmacy and pharmacist are not adequately equipped to provide people with advice and written information about valproate. |
I do not intend to make any changes to the workflow and near-miss/error data will be reviewed regularly. If it becomes apparent a change is needed this will obviously be reviewed. Valoprate pack as promoted on PSNC website after inspection has been ordered and being used in quality payment audit. The card from the pack has been stuck the the shelf in front of valporate. The PMR alerts the staff. Patients are spoken to and this is recorded on the PMR. All staff have been made aware and will be required to read the pack. The cost for the delivery device has prevented its introduction. A drivers paper base delivery log will continue to be actioned and each delivery is documented. All records will be kept for a minimum of 2 months. The MDS process now includes the tray inlay sheet to be signed by dispenser and pharmacist and attached securely to the tray. All conversations regarding each individual patient will be recorded on the patient conversation sheet. |
20/02/2020 | 22/04/2020 |
Pharmacy inspections
Inspection reports and learning from inspections