| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy doesn’t identify and manage its risks adequately. And it operates in a way which increases the chances of mistakes happening. |
A SaferCare champion is to be nominated for the store, then all relevant store colleagues to be trained on the SaferCare process, and the weekly tasks to be restarted. One complete cycle to be completed initially to understand current status, including how daily tasks (dispensing, delivery, etc.) are prioritised appropriately alongside provision of services, e.g. flu vaccinations. |
17/12/2019 | 17/12/2019 |
| 1.2 | Members of the pharmacy team record the mistakes they make. But they don’t always review them to try and stop them happening again. |
All relevant team members to be trained on the near miss process, including training to support on recording, implementing and maintaining tangible actions, as well as Root Cause Analysis, Reflective Statements and the 5 Whys document. Training to be given to the store manager and pharmacist on how to review near miss logs monthly as part of the SaferCare process. |
17/12/2019 | 17/12/2019 |
| 1.6 | The pharmacy doesn’t keep all the records it needs to by law. |
All outstanding prescription register entries completed urgently. All relevant team members to be retrained on recording requirements for private prescriptions, including recording promptly (same or next day) and with all relevant information, including prescriber details. All relevant team members to be retrained on the recording requirements for Specials, including the date an unlicensed product is received from the supplier. |
03/12/2019 | 17/12/2019 |
| 1.7 | The pharmacy team doesn’t do enough to make sure people’s private information is disposed of safely. |
Briefing to be given to store manager and all team members detailing that confidential information must be kept separate from general waste and stored appropriately. |
03/12/2019 | 17/12/2019 |
| 2.1 | The pharmacy doesn’t have enough team members. Staff are under pressure. And they struggle to cope with the pharmacy’s workload and complete all the tasks and training they’re expected to do. |
Review of the current staffing levels against the company staffing profile tool and support accordingly where there may be a deficit; advertising and interviewing new colleagues with support of recruitment agency. Complete the company Right People Right Place Right Time tool to ensure there is an adequate coverage of staff during the working day, including forward planning of rota including cover for holidays. New rota must also allocate weekly training time for all colleagues. All colleagues to have a mid-year review prior to the end of November to formally discuss their training (including FMD), development and objectives. Put in place a suitable and robust contingency plan and escalation procedure to cover unforeseen colleague sickness. |
17/12/2019 | 17/12/2019 |
| 3.1 | The pharmacy’s premises are poorly maintained. And pose potential health and safety risks to people who work at the pharmacy. The pharmacy doesn’t have the workspace and storage it needs for the services it provides. And it doesn’t present a professional image. |
Cause of intermittent water leak to be identified and resolved and decorative state of ceilings and walls to be repaired where showing signs of water damage. Stairwell and corridors to be kept clear from obstruction/hazards at all times. Pharmacy shop front and window frames to be repaired and painted. Decorative state of dispensary walls to be reviewed and improved. Over-worn dispensary floor tiles, as well as skirting and door architraves, to be repaired, recovered or replaced. Pest control to be visit site to remove dried pigeon excrement from upper-floor room, and to determine if ongoing issue. |
14/02/2020 | 25/06/2020 |
| 4.3 | The pharmacy doesn’t do enough to make sure all its medicines are stored appropriately and securely. The pharmacy’s team members don’t make sure spent sharps are stored securely. |
New Perspex units to be ordered to store P-meds, including pseudoephedrine. Meanwhile, P-meds to be kept away from open shelving, i.e. store behind counter. Pharmacy will arrange for authorised witness to witness destruction of large number of expired Controlled Drugs. Purple cytotoxic bin to be ordered, and all relevant team members to be briefed on segregation of hazardous waste as per poster to be displayed beside waste bins. Team will ensure that the consultation room cupboards are lockable, and kept locked, to ensure safe storage of confidential information and sharps. Consultation room not to be used as waiting area for flu vaccinations. |
17/12/2019 | 17/12/2019 |
Pharmacy inspections
Inspection reports and learning from inspections