Sidhu's Pharmacy (1038539) - Improvement action plan

The pharmacy cannot always demonstrate that it carries out sufficient checks to make sure all medicines are appropriately managed.

- Although we have stickers in place to stick on to our medication bags, we will move them and keep them in a more obvious position closer to the dispensing and checking benches. Therefore, they will be in a location where the staff can be reminded to use them. We will retrain the staff and also discuss in our weekly staff meetings that these stickers must be used consistently, and although the ‘CD’ stickers and ‘fridge’ stickers are used regularly, the ‘high risk’ ones must also be used just as regularly. To further ensure this occurs, we will ensure all staff re-read the appropriate SOPs regarding high risk medications and we will do one to ones with them to ensure they understand and are aware of these so they can highlight them. Also, we will tie this in with the point highlighted regarding how our staff answered questions regarding the safe use of high risk medication in compliance packs. Although they were able to answer some of these questions, but once they have been retrained on this, they will be more confident and more aware of this.
- Following on from our previous inspection, we ensured we keep resources regarding the safe use of valproate near our valproate medication on the shelf. Unfortunately, once the leaflets, stickers, and safety record cards were finished they were not replenished. We will therefore, ensure all the resources are re-ordered and kept replenished all the time.
- We have an audit trail in place whereby our prescriptions that are ordered from the medical centre across the road are recorded but due to the frequent visits we make to the surgery during the day and the busy environment in the dispensary, the collected prescriptions were not always being reconciled and marked off as collected. This was giving us problems with sorting out queries and delaying the time it took to receive these prescriptions for our patients. We will highlight this issue to our staff in our weekly meetings and ensure the retrieval of prescriptions will be reconciled each and every time any prescriptions are collected. This will be standard procedure for us now. The responsibility of this from the other surgeries is done thoroughly by our delivery driver who has robust procedures in place to ensure they are aware of each prescription that requires chasing up.
- Our delivery driver goes through all the prescriptions in the morning and organises them into routes. Deliveries are written down and we have an audit process in place, but this requires improvement as it isn’t detailed or robust enough. We will ensure we retrain all three delivery drivers and check they all use the same new process whereby bag labels will be attached in the delivery book highlighting any fridge items/CDs etc and once delivered successfully, they will be marked off so we can check back if any queries occur.
- We will check our flu vaccination records are all neatly organised and stored in one folder kept on our shelves so this is easily accessible. Our flu jab record forms were missing vital information such as batch number, expiry dates etc so all of this information will be written on each form correctly and stored as per requirements.
- Although our date checking is done regularly, one of the books covers medication which will be expiring in each month. We will ensure this is standard procedure and staff are aware to go through each month at the start of the new month taking off the medications that will expire in that month. A new team members will be delegated this task to ensure every month this is done.
- The superintendent pharmacist will chase up regarding the installation of the FMD with SecurMed.
- Although we have a drug alerts/recalls folder, this is not actively being used. We receive majority of our alerts through email so now the superintendent pharmacist will ensure all recalls/alerts are printed off, checked and we record on the sheet that this has been actioned and on which date. This will go straightaway in the folder for future reference. We will ensure all staff are aware of this also.
- We will delegate that the team member who checks the fridge temp daily of the fridge 1 to check the fridge temp of fridge 2 daily as well.
- There are a number of improvements we plan to make in regard to the management of our controlled drugs. All regular pharmacists will update their CPD knowledge regarding this. We will ensure we make changes to the storage of CD destruction kits, and expired stock. We will ensure staff mark opened bottles of methadone with dates.