The Chief Cornerstone (1034910) - Improvement action plan

The pharmacy does not adequately assess or manage the risks associated with its services.

• Risks associated with not having a pharmacist present to be reviewed. And the impact on the safety and effectiveness of services to be fully assessed.
•The pharmacy to conduct a thorough review of the services it provides. And it will ensure that it has suitable resources, appropriate procedures and adequately trained staff to deliver all services safely and in accordance with the law and pharmacy guidelines.
• Risks associated with insufficiently trained staff and the safe delivery of services to be addressed.
• All near miss mistakes to be recorded and discussed with the team member as soon as possible after occurrence and follow up actions put in place to reduce reoccurrence.
• Reviews of near misses and errors to be conducted by the most appropriately skilled and trained member of the team.

The pharmacy does not do have up-to-date or appropriate procedures for the services it delivers. And it does not review them appropriately to ensure the safe and effective running of the pharmacy.

• Standard Operating Procedures (SOPs) to be reviewed up to every two years in line with GPHC requirements or sooner if necessary. All SOPs to clearly identify who (job role) is accountable and/ or responsible for each task.
• Updated SOPs to include all relevant steps for the pharmacy’s team members to follow.
• All staff to read, sign and follow the SOPs relevant to their roles. And compliance with SOPs to be monitored.
• Each staff member to ensure that they use their own smart card.
• All the above procedures and their review dates will be documented to ensure that they comply with timelines.

All SOPs will be reviewed with particular reference to the following:
• RP SOPs
• Deliveries: procedure in place to have documented evidence of deliveries using driver’s delivery book.
• Near misses: Robust procedures in place for recording and monitoring near misses.
• Standard Operating Procedures (SOPs) to be reviewed up to every two years in line with GPHC requirements or sooner if necessary. All SOPs to clearly identify who (job role) is accountable and/ or responsible for each task.
• Updated SOPs to include all relevant steps for the pharmacy’s team members to follow.
• All staff to read, sign and follow the SOPs relevant to their roles. And compliance with SOPs to be monitored.
• Each staff member to ensure that they use their own smart card.
• All the above procedures and their review dates will be documented to ensure that they comply with timelines.

All SOPs will be reviewed with particular reference to the following:
• RP SOPs
• Deliveries: procedure in place to have documented evidence of deliveries using driver’s delivery book.
• Near misses: Robust procedures in place for recording and monitoring near misses.
• Multi-compartment compliance packs: Robust SOP in place for assembling compliance packs without leaving any used tablets in inappropriately labelled and packaged containers.
• Ensuring all medicines used for compliance pack dispensing are in their original containers.
• Updating SOP: procedures in place to update SOP every year.
• Safeguarding: Procedures in place for safeguarding children and vulnerable adults
• Whistleblowing: Procedures in place for whistleblowing.

The pharmacy continues to not keep its records as required by law.

• The RP notice to provide up to date details of the RP on duty.
• The RP notice to be displayed in an appropriate position, visible to the public.
• The RP record to be completed by the RP on duty and a record made of the times at which their responsibilities begin and end. Controlled Drug (CD) running balance checks to be conducted monthly from September 2023. And more frequently where problems arise, or further monitoring is required.
• Patient returns of CDs to be recorded in accordance with guidelines and as soon as possible after receipt.
• Patient returns to be stored in accordance with safe custody requirements.
• CD patient returns to be destroyed, with a witness present where possible, as soon as possible after receipt. This will generally be within 24-48 hours or sooner if necessary.
• CD registers to be kept as required in law. And registers to be kept separate
for each drug, form and strength and brand as appropriate.
• Private prescription records to be recorded as required by law and in a timely manner.
• Special invoices to be actioned and filed in a folder to be kept for five years.

The pharmacy does not do enough to ensure it has team members with the appropriate skills and training for the tasks expected of them.

• Staff level and workload is reviewed in monthly team meetings.
• Staff to be encouraged to report to SI with concerns.
• Medication deliveries: staff capacity and safety measures will be reviewed and assessed monthly.
• Formal staff appraisals to begin in November 2023. Staff appraisals to be held bi-annually where possible, to identify and address any gaps in knowledge, training and skills.
• Informal two-way feedback to be given when required.
• Introduce regular 5 min briefings for any urgent issues, contingencies and any new products or changes to services.

The pharmacy does not do enough to ensure that people can access all its services, appropriately and safely. And on a regular basis.

• SI will ensure that an RP is present to supervise all pharmacy services as required. Contingency plans must be in place to cover any unforeseen absences which may occur during the pharmacy’s contracted hours.

The pharmacy does not do enough to ensure that its medicines are all packaged and stored appropriately. And it does not ensure that it make all the necessary checks to ensure that its medicines and devices are safe or appropriate to use. So that it can protect people’s health and wellbeing.

• A date checking ROTA and cleaning ROTA implemented from September 2023.
• Monthly date checks to be conducted and records kept.
• All medicines to be stored in and dispensed from their manufacturer’s original packaging, without mixing batches or brands. This to be monitored on an ongoing basis by the RP and the SI.
• Medicines requiring storage in the fridge or CD cabinet to be stored appropriately.
• Fridge temperatures to be recorded daily to ensure that all fridge items are kept within the required temperature range. Equipment used to monitor temperatures will be monitored to ensure readings are accurate.
• The pharmacy will conduct regular CD balance checks.