| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have SOPs or risk assessments for its pharmacist prescribing service. And there is evidence that some of its procedures are not being followed or need to be updated which is creating addtional risks. |
A prescribing SOP and risk assessment framework is being developed to reflect the prescribing activities taking place in the Pharmacy. This will be available in the Pharmacy and a comprehensive training program will be initiated to ensure all team members are aware of the scope of the service on offer. The latest versions of all SOP are available on the intranet site, SOP folders have been fully updated to reflect the latest versions available online. The organisation intends implementing an online IT SOP tool which allows each member of staff to electronically sign the latest version of each SOP. This IT solution also provides a ‘live’ audit of which members of staff have signed which SOP to allow the branch’s Lead Pharmacist and the pharmacy’s Superintendent Dept to ensure the latest version of each SOP has been read and signed by all relevant staff. Papers copies will be phased out one the SOP tool is in place to ensure team member uses the latest versions. |
14/04/2023 | 13/04/2023 |
| 4.2 | The pharmacy does not always supply medicines lawfully in relation to its travel services. |
Travel Clinic SOP and protocol to be amended to ensure lawful supply via a PGD based process. |
14/04/2023 | 13/04/2023 |
| 4.3 | The pharmacy does not complete regular CD audits or destructions, so it cannot show it effectively manage its CDs. |
A full CD balance has been completed which did not identify any discrepancies - all registers balanced. Regular CD audits will be carried out as per the pharmacy’s daily checklist/SOP. This checklist is being transferred from paper to an online which will provide live data to the Lead Pharmacist and Superintendent Dept to facilitate interventions where balance checks are not performed in line with the pharmacy’s CD SOP). A new CD destruction process is being set up in line with the new guidance from the NHSE(L) Accountable Officer. SOPs & policies will be sent to the NHSE(L) AO to request approval of an Authorised Witnesses within the organisation. Once an Authorised Witnesses is appointed a CD destruction of patient returned & expired CD stock in line with the CD Destruction SOP will be completed. |
14/04/2023 | 13/04/2023 |
Pharmacy inspections
Inspection reports and learning from inspections