| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not appropriately assess and address the risks associated with providing its services. It does not have written procedures designed to support the safe and effective running of the pharmacy available for its team members to refer to. And they do not always follow safe working practices. |
SOP's are now printed in a physical form, all pharmacy staff working to thoroughly read the SOPs and sign them. Anything they do not understand or would like to discuss about will be done with the superintendent. We are to review the advanced and enhanced services we provide to enable we can safely deliver them. Consultation room has been assesed and anything that can be removed from the room will be done, due to the small size. We have also ensured all equipment in the consultation room is working and patient can have a safe and effective service provided. The drivers have been told not to leave the deliveries unattended outside. |
08/03/2024 | |
| 1.2 | The pharmacy does not do enough to record and learn from mistakes. And team members cannot demonstrate adequate learning from these types of events. |
The Staff have been trained on how to record near misses and dispensing errors on the PMR electronically. The RP have been asked to remind staff to log near misses. Regular reviews will be carried out with staff on how to minimise errors. |
23/02/2024 | |
| 3.1 | The pharmacy is disorganised and untidy so there is not sufficient space for its team members to complete routine dispensing tasks safely. This increases the risk of an adverse event occurring, including a risk of team members tripping and falling. |
We have implemented a new cleaning rota for the pharmacy. Staff have been assigned different areas on a rotational basis. The cleaning will now be done on a daily basis, with all staff carrying out a 'Tidy up Time' twice daily. When the deliveries arrive all the staff are to stop their current tasks and put the order away. All unwanted clutter has been disposed off. Empty wholesaler totes are now not to be stored in the dispensary and rubbish is being collected more frequently. We have assigned designated areas for staff members to have their own workstations. There are now 5 workstations and 2 checking areas. Each person has been made responsible to keep their workstation clean and clutter free. We are also reducing our stock levels of medicines in the pharmacy, to free up more space. We have also changed the shift of 2 staff members from AM to the PM shift. This is to spread the amount of staff in the pharmacy throughout the day. We are also actively looking into finding a bigger premises nearby. |
08/03/2024 | |
| 4.3 | The pharmacy does not store all of its medicines safely and securely. And it does not have effective monitoring processes to ensure it keeps all its medicines at the right temperature and in date. |
The fridge temperature has been logged daily electronically, the PMR reminds every morning to ensure it is carried out. All staff have been informed that medications that need to be kept in the fridge are only to be kept in the pharmacy medicine refrigerator that is being monitored daily. All air conditioning unit have also been checked to ensure they are working to maintain room temperature. We are to rearrange all the medications in the pharmacy. A small section is being done at a time. The medication is taken off the shelf, shelf is cleaned and being put back in the shelves in alphabetical order. Date checking is also to be carried out on a regular basis and importance of stock rotation highlighted with the staff. |
23/02/2024 |
Pharmacy inspections
Inspection reports and learning from inspections