Makepeace & Jackson (1036750) - Improvement action plan

The pharmacy does not always ensure that patient returned medicines which require a record on receipt are documented and stored in accordance with requirements. This may make it harder for the pharmacy to evidence that they are appropriately stored and disposed of.

The Deputy Superintendent of the company has reviewed the pharmacy’s
SOP for ‘Disposal of unwanted meds returned by the public’ and the ‘Controlled Drugs’ SOP (the latter of which has specific section in relation to patient CDs returned to the pharmacy) to ensure compliance with current Standards. In addition, the company’s supporting guidance documents were reviewed. The SOP and supporting guidance documents were then further reviewed by the group Superintendent Pharmacist. They were found to be robust and fit for purpose. As part of this review, CPE and NPA guidance documentation was also reviewed to ensure our policy documents remained compliant and robust.

A training plan for the branch’s Lead
Pharmacist was developed by the Deputy Superintendent. This training plan specifically included the branch’s Lead Pharmacist reviewing the relevant SOPs and guidance documents. To follow up and ensure the training plan has been followed the Deputy Superintendent personally reviewed the afore mentioned SOPs and guidance documents with the pharmacy’s Lead Pharmacist. This was to ensure familiarity with these policies and guidance documents and to ensure compliance with them by the branch’s Lead Pharmacist. The Deputy Superintendent then instructed the Lead Pharmacist to review these documents with all the pharmacy’s staff to ensure their understanding and compliance met the Standards.

Following the review with the Deputy Superintendent Pharmacist, the Lead Pharmacist trained and reviewed the SOP with all members the pharmacy team.

To validate the understanding and compliance with the SOP and associated guidance documents, the Deputy Superintendent Pharmacist has personally interviewed each member of the pharmacy team to ensure they all have the correct understanding.

All team members have signed the SOPs (to provide an audit trail that they have read the SOP)

The Deputy Superintendent has
confirmed a Patient CD Return Register is in branch and all team members are aware of its location and what to do when a patient returns such medication.

The Deputy Superintendent Pharmacist is developing with the IT provider with whom the pharmacy’s SOPs are hosted, a MCQ for all the pharmacy’s staff to undertake which will provide an audit to demonstrate staff understanding of the SOP. This feature is in the development stage with the IT provider, so a definitive date for complication can, as yet, not be confirmed but an initial scoping meeting with the IT provider has been set for5Dec25. It is hoped this enhanced feature will be able to be deployed for Q1 2026.