Famly and Friends Limited (1035903) - Improvement action plan

The pharmacy does not have standard operating procedures (SOPs) available for the team members to refer to, so this may create a risk if they are not following the correct procedure.

Make SOPs Accessible to All Staff
• We have consolidated all relevant SOPs in a dedicated Google Drive folder.
• A physical file of current SOPs is also kept in the dispensary (see attached photographs).
• New and existing team members are shown where to find SOPs both online and in the pharmacy to ensure
immediate access.
• Staff Training Logs and Acknowledgements:
(Maintained in pharmacy records)

Staff Training and Acknowledgment
• All staff are required to review the SOPs and complete an acknowledgment form confirming they have read and understood them.
• A training log is maintained to record each staff member’s progress and sign-off.
• Staff have also been directed to the e-learning modules on the Medlrn platform (linked below) to supplement their understanding.
Ongoing Review and Updates
• We will review SOPs at least annually or whenever changes occur (e.g., new guidance or updated procedures).
• Any updates will be communicated to staff immediately, and staff will sign off on any revised SOP.
• The Pharmacy Manager (Faheem Ahmed) will oversee these updates and maintain a schedule for regular SOP reviews.
Supporting Links & Evidence
• Google Drive (SOPs):
https://drive.google.com/drive/folders/1ZGJ1PYzhJ3vj0iqwikTdmB5zK7_q9nAW?usp=drive_link
• E-learning (Medlrn modules):
https://edu.medlrn.com/courses/pharmacy-assistant-course
• Photographs of SOP Location:
(Attach or reference where the pictures can be viewed.)
• Staff Training Logs and Acknowledgements:
(Maintained in pharmacy records)

The pharmacy does not keep all the records it needs to by law. Its team maintains records of some controlled drugs on photocopied controlled drug register sheets stapled together which do not meet legal requirements. And the responsible pharmacists (RPs) do not always sign out at the end of their session so the RP record is not complete.

Action Being Taken by the Pharmacy
1. Implementation of Legally Compliant Controlled Drug Registers
• We have procured a hardbound CDR that meets all legal requirements (i.e., pre-printed page numbers, permanent record).
• Any old or photocopied sheets are being withdrawn. All data on these sheets are being transcribed accurately into the new official register—ensuring any transcriptions are signed, dated, and referenced to maintain audit trails.
• New SOPs clearly outline how to complete entries correctly, in line with current legislation, including timeliness (entries made on the day or next day at the latest), accuracy, and completeness of each entry (including running balances).
2. Enhanced Responsible Pharmacist (RP) Logging Procedures
• We have reiterated to all pharmacists the requirement to sign in and sign out each day to ensure the RP record is complete.
• A daily check has been introduced by the pharmacy manager (or a designated team member) to ensure the RP signs out before leaving.
• Any omissions are followed up immediately, and corrective entries are made in line with legal guidelines for amending the RP record.
3. Training and Reinforcement
• Staff Training: All dispensary staff and pharmacists have been briefed on the revised procedures for CD and RP recordkeeping.
• Ongoing Refresher Sessions: We hold monthly reminders during team meetings to reinforce the importance of maintaining compliant records and to review any near misses or deviations from these procedures
4. Audit and Monitoring
• Weekly CD Balance Checks: We now conduct weekly audits of CD stock and compare them against the new register to identify and resolve any discrepancies promptly.
• Monthly RP Record Review: The pharmacy manager will review the RP register monthly to confirm that all on-duty pharmacists have completed the sign-out process.
• Any anomalies detected are investigated and documented in an incident log to enable continuous improvement.

Supporting Documents & Evidence
• New Hardbound CD Register (or Approved Electronic Register):
• Photos or screenshots available upon request to demonstrate new record format.
• Example entries showing correct, compliant recording.
• Revised SOPs
• Outlining how to maintain the CD register and complete the RP record.
• Held in the pharmacy’s SOP file and accessible to all staff.
• Staff Training Logs:
• Attendance records and acknowledgment signatures confirming that staff have been trained on new procedures.
• Available for inspection on request.
• Audit Reports:
• Documentation of weekly CD balance checks and monthly RP register reviews (with corrective action records if needed).

The pharmacy team cannot satisfactorily explain how it reports any safeguarding concerns it may have. And it cannot show that it has a written procedure for this. This means it may not be able to help protect vulnerable people as well as it should.

1. Written Safeguarding Procedure
• A Safeguarding SOP has been developed and is now available to all staff (see link below).
• The SOP details the exact steps team members must follow if they suspect or identify a safeguarding concern, including how to escalate concerns to the relevant authorities and any internal leads.
2. Staff Training and Awareness
• All staff are required to read the Safeguarding SOP and complete a training record confirming they understand their obligations.
• We have integrated safeguarding training into our induction programme for new starters, ensuring they know the reporting process from day one.
• Regular Refresher Sessions: We are scheduling periodic safeguarding refresher courses to ensure everyone stays current with policy changes and external guidelines (e.g., local authority updates).
3. Named Safeguarding Lead
• A Designated Safeguarding Lead (DSL) within the pharmacy team has been appointed), who will be the main point of contact for any concerns.
• The DSL maintains up-to-date contact details for local safeguarding authorities (Adult and Child Social Services) and provides prompt support to any team member reporting a concern.
4. Monitoring and Review
• We will review the Safeguarding SOP and training logs annually (or sooner if legislation or guidance changes).
• If a safeguarding incident arises, the DSL will coordinate an incident review to ensure correct procedures were followed and identify any opportunities for improvement.
See attached link to safeguarding SOP

https://docs.google.com/document/d/1NSFnXxi4XNB1VGxeXhptQNwID3oIfcBH/edit?usp=drive_link&ouid=112852584048477152377&rtpof=true&sd=true

The pharmacy allows people to consume their medicines in an insecure area which does not protect their privacy. This creates additional risks for both them and the pharmacy.

1. Designated Private Consumption Area
• We have identified or created a designated area (e.g., a consultation room or a screened-off section) where people can consume medication securely and privately, away from the main retail space.
• Clear signage now directs patients who need to take medication onsite to request or use this private area.
2. Review and Update SOPs
• A new or revised SOP now clearly outlines the process for supervised consumption or any on-premise medication-taking. This ensures staff direct patients to the private area and provide any necessary support (e.g., water, disposal of cups/packaging).
• Staff are being trained to follow this SOP to safeguard patient privacy and protect their dignity.
3. Staff Training and Awareness
• All team members have been re-trained on the importance of patient privacy, confidentiality, and the safe handling of medication consumption onsite.
• This training includes scenario discussions on how to gently guide patients to the private area and how to handle difficult situations (e.g., if a patient refuses).
4. Risk Assessment & Ongoing Monitoring
• We have conducted a risk assessment on the current premises layout, identifying any remaining vulnerabilities.
• The pharmacy manager will periodically review how effectively the new procedure is being implemented (e.g., staff compliance, patient feedback) and make further adjustments if needed.

Supporting Documents & Evidence
• Updated SOP for Onsite Consumption:
• Detailing the process and staff responsibilities for ensuring privacy.
• Staff Training Records:
• Confirming each staff member has received additional training on patient privacy and confidentiality.
• Risk Assessment Report:
• Documenting the changes made to the premises and any planned improvements.