| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy doesn’t adequately manage all the risks associated with its services. Pharmacy team members don’t have access to SOPs that reflect the pharmacy’s current practice. And they are unclear about how to provide services safely in certain circumstances. |
The SOPs will be kept on premises at all times. SOPs will be reviewed every 2 years or sooner if the need arises. |
10/07/2023 | 10/07/2023 |
| 1.2 | Pharmacy team members do not have robust arrangements to learn from mistakes. They do not record or analyse their mistakes. And they do not routinely make changes to their practices to help make the pharmacy's services safer. |
All incidents such as near misses and errors will be recorded and necessary action plans will be made to reduce the risk of these occurring again in the future. Incidents and action plans will be discussed in a staff meeting once a month to help prevent errors from happening again. |
10/07/2023 | 10/07/2023 |
| 1.6 | The pharmacy does not accurately maintain all of its records. CD register running balances are not effectively audited and private prescription records contain inaccurate information. |
CD registers will be audited monthly. The balance column in the methadone register will be now completed on a daily basis and a balance check of the methadone stock will be done weekly. |
10/07/2023 | 10/07/2023 |
| 1.8 | Pharmacy team members do not demonstrate adequate knowledge to be able to effectively manage concerns about vulnerable people. And they do not have a written procedure to help them do this. |
With reference to safeguarding, staff will update their knowledge through accredited online courses. We will produce a written procedure relevant to our team to help them effectively manage concerns about vulnerable people. |
10/07/2023 | 10/07/2023 |
| 3.1 | Several key areas of the pharmacy are dirty and are not properly maintained to ensure the safe provision of the pharmacy's services. |
A new cleaning rota will be implemented, and all areas will be kept clean. No medication will be left on the floor. The bird faeces and other materials present on the stairwells and upper floors of the pharmacy will be cleaned. The opening into the roof from the second floor has now been sealed to prevent further occurrences. The suggested evidence of other vermin such as rodent droppings on the first floor will be investigated with pest control to ensure this is not the case and if so to treat accordingly. This room will also be cleaned to remove any suspected rodent droppings. |
10/07/2023 | 10/07/2023 |
| 3.3 | The pharmacy has inadequate hygiene and infection control measures in place for the safe provision of its services. And this represents a risk to people's safety. |
As 3.1 a new cleaning rota will be implemented and all areas will be kept clean. |
10/07/2023 | 10/07/2023 |
| 4.3 | The pharmacy does not have adequate processes for managing and storing its medicines. It does not have a robust system for checking expiry dates, and there are out-of-date medicines on the shelves. The pharmacy does not keep all its medicines in the original packs, which increases the risk of errors. And it does not always provide people with the necessary written information to help them take their medicines safely. |
A new date checking rota will be set up for the dispensary stock. This will help us to identify any short dated and out of date stock. Patient leaflets will be given to all patients at the time of dispensing. All medication will be kept in their original packs from now on. |
10/07/2023 | 10/07/2023 |
Pharmacy inspections
Inspection reports and learning from inspections