Everest Pharmacy Shaw (1033768) - Improvement action plan

The pharmacy cannot provide assurance that the medicines fridge temperature is being monitored effectively. As a result, it cannot always be certain that medicines requiring cold storage have been kept in the correct conditions and remain suitable for supply. The pharmacy does not ensure that all its medicines which require safe storage are kept secure. This increases the chance of unauthorised access to these medicines. In addition, records of expiry date checks are not maintained. This increases the risk that some medicines may be overlooked, including those that are expired or approaching their expiry date.

Fridge temperature monitoring: The second medicines fridge has now been added to Pharmsmart, the pharmacy’s digital record‑keeping platform. Daily temperature monitoring is now completed and documented for both fridges, and staff have been reminded of the requirement to record temperatures consistently and in line with SOPs. Safe storage of controlled drugs: The specific issue related to controlled drug baskets being left on the bench when the pharmacist was called away to complete a consultation, creating a temporary safe‑storage risk. Controlled drugs requiring safe custody are now fast‑tracked to the pharmacist for immediate checking. CD medicines are always returned to the controlled drugs cabinet for safe storage unless they are actively being checked by the pharmacist and under their direct supervision. If the pharmacist is required to leave the bench at any point, the CD baskets are promptly placed back into the CD cabinet to ensure higher‑risk medicines are never left unsecured. Expiry‑date checking records: Expiry‑date checks were being completed but not recorded. All staff now have individual Pharmsmart logins and have been trained on how to correctly document expiry‑date checks. Expiry‑date checks will now be recorded consistently to provide a clear audit trail and demonstrate compliance with governance requirements.