Peel Green Pharmacy (1033555) - Improvement action plan

The pharmacy team does not have written procedures for some aspects of its services. For example, preparing compliance packs or services to care establishments. Its existing procedures have not been reviewed for several years, and team members have either not read or refreshed their understanding of the procedures for some time. And the pharmacy team does not effectively record and review near misses and dispensing errors, to make sure it learns and makes improvements to its working processes.

Written procedures reviewed or introduced for all services and tasks associated with services.
All staff have read and signed the written procedures relevant to their role and responsibilities.
All staff have read and signed the written procedures for recording near misses and dispensing errors.
The pharmacy has a near miss and dispensing error record that pharmacy team members can easily access.
The pharmacy team has regular monthly meetings to review near misses and dispensing errors.

The pharmacy does not always manage medicines safely and effectively. It has accumulated an unnecessarily large quantity of date expired CDs. Patient returned CDs are not stored according to requirements. The pharmacy does not monitor medication refrigerator temperatures. Some medicine stock does not have a batch number or expiry date, and the pharmacy team does not keep any records to confirm it regularly checks medicine stock expiry dates. The team does not keep records for non-CD deliveries to domiciliary patients.

All date expired CD’s have been destroyed.
All staff have read and signed the written procedure on storing returned CDs.
Thermometers have been installed in both medication refrigerators.
Maximum and minimum temperature records kept for both medication refrigerators.
All pharmacy team members were reminded that medicines without a batch number or expiry must not be kept in stock.
Expiry date check record to be introduced.
Delivery drivers are being consulted on non-CD domiciliary delivery procedures.
The written procedure for non-CD domiciliary deliveries to be subsequently updated.