| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy doesn't have a set of SOPs for the pharmacy team to follow |
We have amended our SOP's to ensure they are fit for TITAN and also for the regular running of the pharmacy. We will now begin to ensure all staff have read these and are signed of. |
29/06/2022 | 01/06/2022 |
| 1.2 | The pharmacy doesn't have a robust procedure to record near misses and dispensing errors. And doesn't have documented review processes. |
1. We will be using pharmsmart website to keep a log of the patient safety and mhra alerts and medicine recalls. |
15/06/2022 | 01/06/2022 |
| 1.6 | Poor management of CDs. No procedures in place to support the safe handling of CDs. CD transactions not entered promptly. Running balances not checked. Patient Returned CDs not recorded or destroyed promptly. Out of date CDs not destroyed promptly. |
We have completed a full cd balance, solved all the discrepancies which where mainly missed entries. We have put a stringent procedure in place to make sure this does not happen in the future and the cd's are entered promptly. We have also ensured that TITAN and CD Smart are both linked and all relevant staff have access to the online register to ensure a running balance is kept. We have entered all the patient returns and have destroyed these. Ken Dale has been to the pharmacy for an CD inspection and has destroyed all of our out of dates. We have closed all our paper registers. We have created an account for the CD reporting tool and will report all CD issues via this. |
15/06/2022 | 01/06/2022 |
| 2.2 | The pharmacy does not support its inexperienced team members enough with training. So they do not have all the skills, competence, or qualifications for their roles and the tasks they carry out. |
1. We have successfully enrolled 5 staff onto the relevant training programmes with the NPA and they have all begin their courses. |
15/06/2022 | 01/06/2022 |
| 4.3 | No fridge temperature records and no procedure in place for recording |
We have created 2 fridge logs on the pharmsmart website for both fridges and ensured all staff know how to check and reset these daily and how to escalate if the temperature is out of range |
15/06/2022 | 01/06/2022 |
Pharmacy inspections
Inspection reports and learning from inspections