| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy does not adequately maintain the records required by law. |
After reflection and review, we will ensure all records are maintained and used effectively. To begin with our SOPs will be reviewed, updated and we will make sure each staff member including all Pharmacists read, refresh their knowledge and sign/date each SOP. All SOPs will be reviewed annually. A near miss folder was present but not located by the Pharmacist on duty during the inspection. After reviewing this folder, we realised it was still not being used as effectively as it should have been so have procedures in place now where any near misses that occur are entered straightaway and then reviewed monthly. Any significant learning opportunities or changes/improvements will be communicated to all staff members. We will encourage the whole team to record and push for a culture of self reporting any errors. Any dispensing incident that occurs will be recorded as we will have a folder in place now with reporting form templates that are accessible to staff members and can be completed at the time of the incident. We will train all staff members and ensure at the time of incident, all information and evidence is recorded and kept and appropriately reported. We will display complaints procedure via posters in the retail area of the Pharmacy so it is easily seen by patients. The Inspector highlighted that although our RP sign in/out records were completed electronically, we were not signing out each and every day and there were dates missed. We will rectify this and ensure the on duty Pharmacist signs both in and out of duty every day. Our private prescriptions will now be entered daily into the register as we will highlight this to all staff members and ensure it is part of the daily tasks completed. We will ensure this duty is given to one of the Pharmacists. The record keeping of controlled drugs will be safely and legally recorded. We will conduct a meeting between the regular Pharmacists and ensure all the invoices and prescriptions will be entered and a full balance check carried out. We will ensure all balances are correct and accounted for accurately. Again, this will be put into standard daily procedure, and the Pharmacist must ensure all controlled drug prescriptions are entered on the day of supply/receipt. All staff including delivery drivers will be aware of this and we will have a allocate basket in place to hold all controlled drug prescriptions and invoices from that day. Going forward, weekly balance checks will be conducted to ensure we are maintaining this. We will also go through and check that all CD record books are kept neat and tidy and as the Inspector reported, we will re-organise the CD cabinet and ensure all stock is arranged in a neatly fashion. We will organise our ‘specials’ folders and ensure all appropriate records are kept for each medication supplied. This will include all invoices and certificate of conformity. Although we have these folders, they do require organising and all information recorded in a timely and neat fashion so it is readily accessible. |
05/07/2019 | 23/08/2019 |
| 4.3 | The pharmacy does not carry out adequate checks to ensure that medicines are suitable for supply and disposed of appropriately. |
In order to safely supply and dispose medicines, we will work alongside our team and implement different working methods. To achieve this, we will hold staff meetings to ensure all staff members are aware of the improvements. High risk medicines will be highlighted on the shelves with coloured shelf edge labels and where literature is needed, we will keep these alongside the medicines so the team can remember when dispensing. We will update our literature and make sure we have the leaflets, cards etc needed for lithium, sodium valproate etc. Staff will be re-trained on the safe disposal of medicines and we will ensure a new SOP is in place highlighting gabapentin, pregabalin and tramadol and their safe disposal. We will also order a cytotoxic bin. Although our services are advertised on the television screen, we will make sure our services list is displayed in the window of the Pharmacy so it is clearly visible to all who walk in or walk by. This will include all essential, advanced and enhanced services we offer. We will also create a leaflet stand where our services will be advertised more clearly to patients and they can freely take away literature. On our retrieval shelves, some prescription bags had no prescriptions attached so we will implement changes in our dispensing process to ensure each bag must have a prescription attached. Also, in line with this we will introduce new stickers which must be used highlighting the expiry date of any CDs eg. Zopiclone to ensure they are supplied safely. At present, due to the level of repeat requests we are not keeping record of what prescriptions are being ordered from the surgery across the road and therefore have no audit trail in case of queries. To avoid this, we will be introducing a new step where once prescriptions are requested, and before they are handed across the road, a bag label is to be stuck into the diary under the correct date of ordering and these will be checked against the prescriptions that are received electronically. This will also help improve our query handling and smoothen our dispensing process. Our weekly blister packs at present have no patient record sheets containing medications, doses, time of doses etc. So, we will be making sure each blister pack patient has a sheet showing this information and if any changes in medication etc are notified, they are added to these sheets ensuring effective communication between staff members. Our service specification for our Minor Ailments Scheme is updated now and a new copy is filed in the folder. To ensure we do not keep an expired service specification again, we have recorded the date on our calendar and highlighted the renewal date for next year to prompt us again. Although our delivery drivers are aware of obtaining patient signatures, some have been missed. To avoid this, we will re-train our delivery drivers and ensure this is completed each and every time. We will be having a complete date check of all stock and ensure our date checking folder is kept up to date and stock regularly checked. Although we have a sticker system in place, out of date stock was not being removed so we will now record stock that will expire under the month it will be going out of date so at the beginning of each month, it can be removed efficiently. Whilst doing this, we will ensure all stock is re-organised in a neat and tidy fashion and strengths are segregated safely. To ensure safe supply of medication, as mentioned earlier, the CD cabinet will be tidied and re-organised and all stock will balance. We will delegate the recording of both fridge temperatures to two members of staff so they know that twice a day, both temperatures are to be checked and recorded and the Pharmacist to be informed if too too high/low. These will be kept in a new folder which will be clearly highlighted and accessible. We will create a new folder for drug alerts and recalls and train all staff that if they come across and emails regarding this, they are to print, action and sign/date this and record in the file. This will ensure that although read and actioned, we have evidence and an audit trail. We have now ordered a new set of glass measuring flasks which are marked with a British Standard approval. |
05/07/2019 | 23/08/2019 |
Pharmacy inspections
Inspection reports and learning from inspections