The Blackbrook Pharmacy (1036356) - Improvement action plan

The pharmacy does not keep all the records required by law and does not have good governance procedures for the management of controlled drugs. It does not keep accurate records of the storage and supply of controlled drugs.

1.6a) Regarding RP Record we will highlight the need to sign out on a daily basis to form a more complete record electronically.

1.6b) A full Controlled Drugs stock count to be conducted week commencing 5th Feb 2024.
This is to be compared to the current stock level in the electronic CD Register and the report of discrepancies reported to NHS England CD Accountable Drugs Officer as an incident using the online reporting website.

1.6c) The CD Stock count figures are then to be used as ‘Opening Stock Balance’ for each Controlled Drug in newly acquired CD Register Inserts to form new Controlled Drugs paper Register. These inserts will be purchased this week.

1.6d) A new Controlled Drug SOP has just been written and will be reviewed in light of this report to see if any further additional points need highlighting within it. This will then be finalised and signed by all staff.

1.6e) Weekly Balance counts to be set up by the Pharmacy with a view to count /balance check all CDs over a rolling 2 week period.

1.6f) A separate CD Insert for Patient Returned CDs to be set up into which will be recorded initially the current patient CD returns we have in the cabinet. The need for immediate recording into this register any CDs returned to the Pharmacy by patient/representative will be stressed.

1.6g) Meeting conducted regarding changes to the running of the Methameasure / supply of Methadone to patients on blue scripts. Pharmacist to check script / screen at time of pre-administration then immediately fill out the right side of the blue script to record the entry.

Both GPhC Inspector and Accountable Drugs Officer to be kept informed of completion of these Action Points.