| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not identify and manage the risks associated with all its services adequately. |
Pharmacy to review Standard Operating Procedures (SOPs) for near miss and incident reporting: All staff to retrain in the use of near miss logs and record learning points. Progress to be monitored by RP and SI |
29/11/2023 | 29/11/2023 |
| 1.6 | The pharmacy does not ensure that it keeps its records in the way the law requires. |
Pharmacy to review and amend, if necessary, the Responsible Pharmacist (RP) SOPs to ensure compliance with legal requirements. All RPs to complete the RP record and display their RP notice as required by law. Superintendent (SI) to monitor responsible pharmacy logs on daily basis. All the following SOPs to be reviewed. Staff to be retrained on the correct procedures to follow: CD registers to be reorganised to ensure they are easy to find and use and to ensure that they are kept in the way the law requires. |
29/11/2023 | 29/11/2023 |
| 4.3 | The pharmacy does not store all its medicines in appropriate packaging which is properly labelled. And it does not make all the checks it should to ensure that its medicines are safe to use to protect people’s health and wellbeing. |
To arrange for the destruction of expired CD stock in accordance with legal requirements. SI to review staff compliance with the following SOPs: Dispensary shelves to be tided and maintained in an organised manner. All stock to be date checked as a matter of urgency. Any stock which has either expired or is close to its expiry date, to be removed. Date checking records to be completed as per SOP. Responsible pharmacist to carry out visual and manual checks of shelves and expired log sheets and sign accordingly. Fridge – to be operated in accordance with the SOP- all staff to review SOP and sign to indicate compliance. New fridge data logger to be used. Continue to record the temperature of both fridges on PMR system daily. |
29/11/2023 | 29/12/2023 |
Pharmacy inspections
Inspection reports and learning from inspections