| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy's procedures are unclear, so team members may not understand their responsibilities or work effectively. |
The standard operating procedures (SOPs) will be reviewed and updated. Paper copies will be available within the pharmacy for easy access. All members of the staff including regular pharmacists will be required to read and sign/date each SOP, this will ensure all staff members are clear about their roles and responsibilities. All SOPs will be reviewed annually to ensure procedures are up to date. |
21/07/2023 | 26/07/2023 |
| 1.2 | The pharmacy does not always take appropriate action to ensure team members learn from incidents. |
All near misses will be promptly entered into the near miss register. The responsible pharmacist will ensure all staff members enter any near misses as soon as they occur. Any dispensing incidents will be formally recorded in the incident logbook, including incidents which have already been resolved by verbal or written communication. The incident logbook contains a template which should be used to complete the report. The report should be completed by the responsible pharmacist on duty or by the manager. |
21/07/2023 | 26/07/2023 |
| 1.6 | The pharmacy's records are unreliable. The reponsible pharmacist log and private prescription register are incomplete. This means the pharmacy cannot always show what has happened and that all supplies of prescription only medicines are safe and legal. |
The responsible pharmacist log will be placed in an area where it is easily seen to ensure the pharmacist on duty completes the register every day. The missing entries will be rectified, and all pharmacists will be reminded that is their duty to sign in/ out when on duty. A new private prescription book has been created to ensure records are appropriately maintained. The importance of entering private prescriptions daily has been highlighted to the regular pharmacists. Private prescription forms will be kept in a folder to ensure a complete audit trail. Records for the procurement and supply of specials will be appropriately maintained according to legislation. The specials folder will be re-organised and easily accessible for all staff members. The online controlled drugs (CD) will be completed daily by the responsible pharmacist on duty. |
21/07/2023 | 26/07/2023 |
| 4.3 | The pharmacy cannot demonstrate that it stores and manages its medicines appropriately so that they are fit for supply. |
Prescriptions will be attached to all dispensed medication that is filed away for collection to ensure staff members have medication information when handing out prescriptions to patients. Medication filed away on shelves for controlled drugs such as gabapentin and tramadol will be clearly marked with a CD sticker. Medication filed away on the shelves will be checked every month and uncollected expired CD prescriptions will be removed after 28 days, other prescriptions will be removed after 3 months on the retrieval shelves. We are currently updating our master medication records for blister pack patients, so all patients will have an up-to-date record of their medication including any recent medication changes. A few changes have been implemented when dispensing and preparing blister packs, this includes a patient label on all packs, medication descriptions written on backing sheets and all packs are supplied with patient information leaflets. The dispenser preparing the blisters packs and the pharmacist who checks the packs are required to sign each pack to ensure a clear audit trail. In addition, all loose medication stored in containers ready to be dispensed for blister packs have been removed. We are currently date checking the entire dispensary, each member of staff has an allocated section and must complete their section within a certain time frame. Out of stock medication will be removed from the shelves and placed in the medicines waste bins. Stock which is expiring within 3 months will be marked with a yellow sticker. Stock expiring at the end of the month will be marked with a red sticker and will be removed at the end of the month. The shelves will be cleaned and re-organised, medication that is short dated will be placed at the front of the shelves. All staff members are aware that medication must be stored in the original packaging on shelves, loose blisters are not allowed. The recording of the fridge temperatures has been delegated to two members of staff. A new fridge temperature record folder has been made and the temperature for both fridges is checked daily. The pharmacist will be informed if the reading is too high or too low. If the fridge is not within the required temperature range, it will be reset and checked again. A new form has been made for drug alerts and recalls, the form should be signed and dated when actioned to ensure a complete audit trail. All staff members have been trained on how to access alerts through email or through the GOV.UK website. Paper copies of the patient group directives (PGDs) for the travel vaccinations we offer will be available in the pharmacy for easy access. Records will be maintained in accordance with the PGDs. |
21/07/2023 | 11/08/2023 |
Pharmacy inspections
Inspection reports and learning from inspections