Alpha Pharmacy (1040656) - Improvement action plan

The pharmacy is not maintaining all of its records in accordance with the law. This includes the RP record and records for private prescriptions. Staff have not kept appropriate records of Controlled Drugs brought back by the public for disposal. At the point of inspection, the team was unable to provide records for unlicensed medicines or all of the private prescriptions dispensed in the pharmacy

• Inform and remind all pharmacists that the RP record is a legal document and therefore all entries should be made in chronological order and unaltered, they must not be cancelled, obliterated or altered. Corrections made must be made by dated marginal notes and amendments should be initialled and
dated with the pharmacists GPhC number.
• Pharmacists will be informed that CDs returned by patients should be entered in the register for patient returned CDs at the point of arrival and not made at the point of destruction.
• A Folder has been made for the invoices/ certificates for unlicensed medicines and which must be kept for 5 years.
• All private prescriptions are to be filed in chronological order, and all entries are to be made upon receipt.

There is not enough assurance that the pharmacy has a robust process in place to manage and learn from dispensing incidents. Staff are not routinely recording near misses, their dispensing incidents are not recorded in a way where details can be easily retrieved, full details are not documented and there is limited evidence of remedial activity or learning occurring in response

• Ensure all staff members are aware of the location of the near miss/incident log, and instructions on how to make an entry.
• Highlight to all staff on the importance of recording near misses and incidents.
• Discuss incidence with all members of staff involved, undertaking a root-cause analysis. As well as to establish methods on how to overcome the error and stop it being repeated

Pharmacy services are not provided by staff with clearly defined roles and clear lines of accountability. There is evidence of errors but there are no audit trails in place to identify who was involved, the roles and responsibilities of staff are not clearly documented, the pharmacy's SOPs do not make it clear where responsibility lies for different pharmacy activities. The pharmacy is not routinely maintaining audit trails so that it can always identify who was responsible for any professional activities

• Ensure all staff members are aware of their roles and responsibilities.
• Create a document that clearly outlines each staff members roles and duties, which is signed and dated once read by the staff.
• Ensure all pharmacy dispensary staff are signing off medicines when being dispensed and checked, to ensure an audit trail can be established in case an error arises and therefore to identify who was involved.
• Ensure SOPS clearly explain and highlight the roles and responsibilities of each staff member.

The pharmacy does not have enough staff to safely and effectively provide pharmacy services

• the owner is aware of the situation and has put out advertisements to recruit more members of qualified staff; qualified MCA and pharmacy technician.
• The owner/ manager has set his hours to 9am-7pm Monday to Friday
• The pharmacy has recruited part time pharmacy student(s) working 2 days a week

Pharmacy services are not provided from an environment that is appropriate for the provision of healthcare services. Most of the pharmacy is extremely cluttered, this includes the consultation room, there are several unnecessary items present in the back area, dispensed medicines stored here in plastic bags are not sealed appropriately to prevent contamination from spiders and staff are not ensuring that the fire exit is kept clear at all times in line with Health and Safety legislation

• ensure the pharmacy environment is always clean, organise and not cluttered.
• Hiring a cleaner
• Clearing the back storage area to ensure that the fire exit is kept clear.

Pharmacy services are not managed or delivered safely and effectively. The team is not using dispensing audit trails, prescriptions are not used during the dispensing process or when dispensed medicines are handed-out, staff are routinely claiming payment for medicines before they have been collected by people, owing slips are not routinely used, compliance aids are sometimes left unsealed overnight, descriptions of medicines and Patient Information Leaflets are not routinely provided when people are supplied with these, and people prescribed higher-risk medicines are not routinely identified, counselled or relevant checks made

• Ensure prescriptions are used throughout the dispensing process i.e. print the eps token and use it to pick stock and for final check and when handing out.
• Ensure prescriptions are only claimed once medicines have been collected by the patient.
• Inform all dispensary staff that Owing slips must always be used when issuing part supplies.
• Inform all staff to make sure all stock is available prior to starting a dossette box to ensure compliance aid and is not left unsealed. In addition, descriptions of medications are to be written and PILS are to be provided and supplied with every dossette box supplied.
• Identify patients prescribed with higher risk medicine and provide them help and advice