Richardson Pharmacy (1041718) - Improvement action plan

The pharmacy team does not follow standard operating procedures for all activities.

The pharmacy now has a full file of SOP’s.
There is a mastercopy which will stay on the premises and we have made a duplicate file. This file will be taken home by a member of staff each evening in rotation until the SOP’s have all been read,understood and signed by all staff . Once this is undertaken there should be no doubt and deviation following the SOP’s.Where possible I have attached copies of some of the SOP’s to the walls where certain activities take place ,for example the SOP’s for venalink dispensing are all in the basement where they are dispensed.

The pharmacy does not maintain records in line with good practice and legislation. This includes controlled drug and patient returned controlled drug registers. And private prescription and responsible pharmacist records.

I will seek advice form someone on the Tayside Health Board regarding a Complaints procedure. I do send a quarterly complaints form to them if there has been any major complaints.
The staff have been informed that the prescriber’s address must be recorded in the private prescription book .
We are in discussions about using an electronic CD register..
We will now audit the methadone weekly and record the volume and date on a chart beside the Methameasure.
The Responsible Pharmacist Record book will be left out on the dispensary bench the evening before for the phamacist to sign first thing in the morning.
I will ensure the patient’s return CD register is kept up to date.

The pharmacy does not have a culture of learning. It has not acted on areas of improvement from a previous inspection. e.g. out-of-date controlled drugs, confidentiality training, training and development and near-miss recording.

The out-of-date drugs mostly have been destroyed and the CD destruction officer is returning after Christmas to complete this.
We have destroyed all our returned CD’s and from now we will destroy returned CD’s on the day of return to prevent a build up in the CD cupboard.
I will remind staff of the need for confidentiality and shredding confidential information.
Training and development is something we will work on with regular monthly meetings with each member of staff, and also to hear of their hopes and suggestions and at this point we will review the near misses. Our Saturday has now been enrolled on Buttercups Training.

The pharmacy stores confidential information in an area where there is a risk of members of the public seeing it.

Since our inspection,the confidential information files have been moved to the office downstairs where the public have no access .