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Pharmacy inspections

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King Cross Pharmacy (1039549) - Improvement action plan

GPhC Reference 1039549

Standard not met	Reason	Action being taken by the Pharmacy	By when	Notification By Pharmacy Improvements Made
1.1	Pharmacy team members don’t always identify and manage the risks with the pharmacy’s services. For example, they don’t appropriately manage the risks when dispensing liquid medicines and for items stored in the fridge. The team doesn’t always follow the pharmacy's documented procedures. And, the pharmacy doesn't have robust processes to manage the risks of providing medicines in multi-compartment compliance packs.	New SOPs to be implemented. All staff to read and sign SOPs and to be trained where required.	20/02/2020	17/09/2020
1.2	The pharmacy doesn’t keep regular records of near miss errors. The last record is from February 2019. And it only keeps records of some dispensing incidents. There is little evidence that pharmacy team members learn from the mistakes or make changes to stop similar errors in the future.	New SOPs to be implemented. New near miss log implemented. Staff to be trained to highlight any potential errors that can arise. Monthly review of errors with staff to be done and documented unless any errors warrant immediate action.	20/02/2020	17/09/2020
1.4	The pharmacy does not adequately respond to feedback. It has not maintained the changes following feedback from the inspector in the previous inspection in 2017.	New SOPs to be implemented. Pharmacy manager responsible to relay feedback to all staff and to document this.	20/02/2020	17/09/2020
1.6	The pharmacy, over a prolonged time, does not keep all the necessary legal records. And, it does not adequately maintain other records necessary to help manage the delivery of safe and effective services. This is a continuing issue	New SOPs to be implemented. All running balances to be documented monthly. CD destruction log to be maintained as per SOPs. New computer system requires staff/ pharmacist to record both fridge temps before any access to the system can be achieved. New computer system prompts staff to record emergency supply reason – training will be re-inforced.	20/02/2020	17/09/2020
1.7	The pharmacy does not adequately manage the disposal of confidential waste. And, it does not have processes in place to properly restrict access to NHS electronic systems.	New SOPs to be implemented. New shredder in the dispensary. Pharmacy manager in the process of getting new smartcards issued for relevant staff.	20/02/2020	17/09/2020
2.2	Pharmacy team members do not have the right qualifications for their roles and the services they provide. And, they are not enrolled on appropriate training courses.	Pharmacy manager in the process of enrolling staff on the appropriate NPA courses.	20/02/2020	17/09/2020
4.2	The pharmacy cannot evidence, that during dispensing, it takes appropriate steps to make sure some liquid medicines are supplied accurately and safely to people. The pharmacy does not have a robust process to adequately manage the risks when providing medicines in multi-compartment compliance packs.	New SOPs to be implemented. All staff to read and sign SOPs and to be trained where required.	20/02/2020	17/09/2020
4.3	Pharmacy team members do not regularly monitor the temperature of the medical fridge storing medicines. They don’t take any action when the temperature is out of range. And they don’t ever monitor the temperature of the fridge storing people’s medicines waiting to be collected. So, there is a risk medicines are not safe to supply to people. Pharmacy team members do not monitor the temperatures in the medicine fridges. So, there is a risk the medicines are not safe to supply to people. And, they do not provide medicines information leaflets to people receiving their medciens in multi-compartment complaince packs. Or, provide descriptions of the medicines in the packs, so people can identify what they look like.	New SOPs to be implemented. New computer system requires staff/ pharmacist to record both fridge temps before any access to the system can be achieved. Staff to be trained to highlight any issues with the both fridge temps to the responsible pharmacist as per SOPs. Patients receiving multi-compartment compliance packs to receive medicine information leaflets every month. If a new medicine is issued a leaflet will be provided with the relevant pack. New computer system prints a backing sheet for all compliance packs with all the relevant information, including the description of the medicines. This is attached to the compliance packs. Staff are being trained on how to use the new computer system.	20/02/2020	17/09/2020
5.1	The pharmacy does not have the necessary range of equipment available to accurately and safely measure and dispense liquid medicines.	New measuring cylinders have been ordered and in place in the dispensary.	20/02/2020	17/09/2020

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