| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy team members do not always follow the standard operating procedures. They dont have a robust process for checking some prescriptions. And they cannot evidence a full audit trail. And this is creating a significant risk. |
All members of staff to read and sign all SOPs. All staff to follow all SOPs and ensure that the correct processes are being followed. All prescriptions that are suitable to be checked by ACT must be clinically checked by Pharmacist and annotated as such. |
07/10/2019 | 20/11/2019 |
| 1.2 | The pharmacy does not have a system for assessing the safety and quality of its services. And this prevents it from learning and from making needed safety improvements. |
An updated error/near miss log is being used, with all staff able to update it not just the pharmacist. All near misses are to be recorded and discussed with staff on a monthly basis to identify trends and learning needs. |
07/10/2019 | 20/11/2019 |
| 1.7 | The pharmacy does not identify, separate and safely destroy personal information. |
All confidential waste is now separated into a dedicated bin. Paper is then shredded and labels are left in water and bleach until blank. |
07/10/2019 | 20/11/2019 |
| 2.2 | The pharmacy has not trained, or arranged to train, members of the pharmacy team for their roles. They do not meet the minimum training requirements. |
Members of staff that haven’t been trained on Sales of Medicines are to be enrolled on this immediately. |
07/10/2019 | 20/11/2019 |
| 4.3 | The pharmacy does not safeguard medicines from unauthorised access. And it does not use the security controls that are available to it. |
Store room is now always locked at all times. This includes when staff are in this and when they are not. |
07/10/2019 | 20/11/2019 |
Pharmacy inspections
Inspection reports and learning from inspections