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Pharmacy inspections

Inspection reports and learning from inspections

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Abbotswell Pharmacy (1041591) - Improvement action plan

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

The pharmacy does not manage all risks. It does not have standard operating procedures. And the pharmacist routinely self-dispenses and checks. Untrained team members undertake dispensing activities. Ans they do not use dispensing tools like baskets to separate people's prescriptions.

SOPs being updated.
Dispensing baskets being introduced for all Rx. Speak to another pharmacist to discuss their processes.
Ensure adequate break between dispensing and self-checking.

12/11/2019 18/11/2019
1.2

The pharmacy does not monitor and review dispensing, it's main service. Team members do not record or review near misses. And are missing opportunities to learn and improve safety.

Re-introduce near miss logs.
Ensure all staff use them.
Review these regularly to identify themes/trends.
Make changes to improve accuracy.

12/11/2019 18/11/2019
1.3

Pharmacy team members do not understand their roles and responsibilities. They have no processes to follow. And they undertake activities they are not trained for.

All staff to read and sign GPhC guidelines and standards.
Enrol staff on accredited MCA and dispensing asst courses

12/11/2019 30/10/2019
1.4

The pharmacy had no way for people to give feedback. So it could not use feedback to improve services.

Put up notice in pharmacy directing people to the pharmacist to give feedback, positive or negative.

12/11/2019 18/11/2019
1.6

The pharmacy does not keep and maintain required records in line with legislation and standard practice.

Update SOP to include regular audit of all CDs.
Maintain running balances.

12/11/2019 18/11/2019
1.8

The pharmacy team has not had any safeguarding training. The pharmacy does not have safeguarding processes in place. And team members do not know how to raise concerns.

All staff to access and familiarise themselves with content of NumarkNet NHS safeguarding app.

12/11/2019 30/10/2019
2.1

The pharmacy does not have enough trained and qualified team members to safely deliver pharmacy services.

As 1.3.
Three staff members enrolled on appropriate accredited courses.

12/11/2019 24/10/2019
2.2

Team members are not trained, or are not undergoing training appropriate for their role as per GPhC minimum standards. And the pharmacy does not provide material or time for team members to maintain and develop their skills for the services provided.

Team members will be given time at work to complete accredited courses.
And all team members will be given time at work each month to read relevant information or complete training modules required for their roles.
And records will be kept.

12/11/2019 18/11/2019
2.4

The pharmacy has no process in place to learn from experiences. It has not sustained improvements from failures identified at the previous inspection.

Ensure staff are able to recognise failures and bring them to the attention of the owner.
Numark counter excellence whistle blowing policy issued to all staff to read and familiarise themselves ith.

12/11/2019 18/11/2019
4.2

The pharmacy does not manage services safely and effectively. It does not use tools, such as basket, to separate people's medicines. This increases the risk of mixing medicines. It does not keep audit trails of team members involved in the dispensing and checking of items. Particularly those that are self-checked. And people's identity is not confirmed when handing out medicines. This increases the risk of people getting the wrong medicine.

Use dispensing baskets.
Update SOPs and all read and work to.
Always use disp/check by boxes.
Ask people for ID such as address or date of birth even although most people are well known to staff members.

12/11/2019 18/11/2019
4.3

The pharmacy does not always store medicines appropriately or legally. It does not check fridge temperatures and does not lock cupboards. It does not store keys securely and does not destroy out-of-date medicines when it should.

New procedure implemented for CD security when owner is not present.
Log book introduced to record access to keys.
CD cupboards locked at all times.
New fridge to be ordered with temperature control records.

12/11/2019 18/11/2019