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Pharmacy inspections

Inspection reports and learning from inspections

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Well (1035697) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

The pharmacy team is struggling to complete the workload required. And this has led to shortcuts to the way it provides some of its services. And inappropriate management of space in the dispensary.

Complete full review of Pharmacy, Best in Class processes and One Standard.
Prescription Management
Retrieval Management, including maximisation text messaging service.

Regional support colleague to work in the pharmacy twice a week over the next 6 week period. To assist with implementation of Best in Class operational processes.

Request assessment for minor works. Review additional shelving solutions for storage of assembled prescriptions awaiting Accuracy Check.

19/12/2019 19/12/2019
2.1

The pharmacy authorises its team members to work overtime. But it does not have the staffing profile to cover the overtime on some occasions. And some pharmacists providing cover at the pharmacy do not have prior training relating to the pharmacy’s offsite dispensing service. There is evidence this has impacted on workflow in the dispensary. And the way the team completes some tasks.

Review staffing levels and skill mix. Complete the Staffing and Capability assessment document.

Complete and maintain 6 weeks forward planning staff rotas and task matrix.
Assess rota’s against workload and identify any shortfalls. Including prioritisation of Responsible Pharmacist cover by employees who are familiar with Well.

Permanent Pharmacist recruited to work full time in the pharmacy to provide continuity. Commences January 2020.

Continue recruitment of 16 hour vacancy to provide dispensary support for absences and overtime needs.

Full induction to be completed for new starters upon commencement of employment.

Hold a conference call to re-brief employee relief Pharmacists within the Region on Central Fulfilment operating procedures and ‘ongoing’ validation requirements.

Printed copy of the Central Fulfilment guide to be readily available at the start of Responsible Pharmacist shift if required for reference.

19/12/2019 19/12/2019
4.2

The pharmacy team members do not always follow the pharmacy's procedures. They do not keep detailed records of prescription requests they make. And they do not always effectively deal with any queries that result from this. And the pharmacy team does not always complete the checks that will identify any issues with the offsite dispensing service. This means the pharmacy may miss opportunities to identify and manage queries or safety concerns.

Complete full review of Pharmacy, Best in Class FRPS process. Including read of SOP.

Engage with GP Surgeries. Agree process with GP Surgeries for those patients who place their own prescription medicine requests.

Re-train all colleagues on end to end Central Fulfilment operating procedures. Including ‘ongoing’ quality assessment and validation requirements.

Utilise Central Fulfilment to maximise off site dispensing. Ensure packages received back to store are stored on correct shelving and in a timely manner.

19/12/2019 19/12/2019