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Pharmacy inspections

Inspection reports and learning from inspections

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Doctor Care Pharmaclinic (1041445) - Improvement action plan

GPhC Reference 1041445

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

The prescribing service risk assessments are incomplete and some risks associated with higher-risk medicines are not being adequately addressed.

The pharmacy’s standard operating procedures are not always relevant to its services, and there is no assurance that the team understand them. So, members of the team may not always be clear what is expected of them.

1) The service risk assessments will be reviewed; a risk assessment of quantities offered by the service will be carried out.
2) High risk medicines supply will be ceased until further safeguards can be implemented to ensure patient safety.
3) Team meeting will be held to ensure staff understand their roles and responsibility.

 26/09/2022 13/08/2022
1.6

The pharmacy does not keep adequate records of its prescribing decisions. It does not maintain a complete record of private prescriptions it has dispensed and the records of patient-returned medicines are inadequate.

1) The prescribing service will implement the functionality to ensure appropriate notes can be recorded on the patient record for audit purposes.
2) Treatment of return medicines – accept unwanted medicines – avoid needles, sharps, chemicals and hazardous materials.
They are kept in a separate waste disposal bag and sorted accordingly to solid/liquid/aerosols.
Any patient identifiable information is removed.
For CD returns (especially schedule 2/3) take in persons details if required. If unable to denature/destroy immediately then it will be stored inside the CD cabinet according the safe custody regulations clearly separated in a bag labelled ‘returned CD’s’. Then collection will be scheduled from an appropriate collector.
CD balance check will be done every month.
Private prescription register will be used to record private rx details. All private rx’s will be stored in a folder and kept safely.
Out of date CD’s, will be kept separate from the rest and clearly labelled ‘expired’.
Make a record in the CD destruction register after denaturing in the presence of a witness.

 26/09/2022 03/10/2022
1.2

The pharmacy cannot demonstrate that it learns from things that go wrong. And it cannot provide any evidence that it reviews the safety or effectiveness of its prescribing service.

1) The service was re-launched briefly at the time of the inspection. The SOPs indicate the intention to carry out 3-monthly audits on prescribing.
2) The service was thoroughly risk assessed prior to re-launch and considerable changes were made to align with the guidance provided by the GPhC.

 26/09/2022 28/07/2022
3.1

The pharmacy's website allows people to start a consultation from the page of an individual prescription-only medicine.

1) The service will re-design the flow to ensure patients cannot select a product and check out. They will be re-directed back to the medical condition page as per GPhC guidelines

 21/11/2022 14/07/2022
3.4

The pharmacy does not adequately protect all areas from unauthorised access.

1) Confidential waste bags are no longer kept in the cupboard upstairs. Now kept downstairs in the basement.
2) A retractable barrier is now placed to protect of any unauthorised access to the basement.

 12/09/2022 14/07/2022
4.2

The pharmacy does not always share information with people’s regular prescribers when it prescribes medicines for long-term conditions which require ongoing monitoring. And there is some evidence of inappropriate supplies of inhalers to people who have indicated that they do not take other asthma treatments.

1) The service will implement functionality to ensure the prescriber can oversee GP consent to ensure appropriate contact was made by the pharmacy team.
2) High risk medicines i.e. Ventolin inhalers will be ceased until further safeguards are in place to ensure supply is appropriate.

 26/09/2022 09/09/2022
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