| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy does not always maintain accurate records for all of its higher risk medicines. And it does not resolve problems with the accuracy of these records in a timely manner. |
All pharmacy colleagues to re-read SOP 15 Management of Controlled Drugs, SOP 16 Substance Misuse and Best in Class Controlled Drugs Management and Substance Misuse. Ensure CD cabinet is arranged and organised as per Best in Class. Area Operations Manager (AOM) to confirm the pharmacy team are entering the supply and receipt of CD as per SOPs. Report any unresolved discrepancies via internal reporting system to allow Superintendent’s Team to notify Accountable Officer. AOM to support the investigation of the identified discrepancies. AOM to visit the pharmacy weekly and complete a CD Audit as per company framework. Near miss, PSI recording and PSR report: Ensure a monthly patient safety huddle is conducted to discuss the learning from the near miss and PSI and record the learning from the monthly patient safety report (PSR). Ensure the company online log is used to record the RP log. |
25/10/2024 | 22/10/2024 |
| 2.1 | The pharmacy does not have enough suitably qualified team members to ensure it can operate safely and effectively. |
Review the current staffing levels against the company staffing model (MaxE) and identify any recruitment needs at the pharmacy. AOM to support any recruitment of this pharmacy. Ensure the pharmacy team are aware of any planned annual leave from the relief team. Ensure the pharmacy team have a 6 weekly rota as per company process. Ensure any staffing challenges identified on the rota are addressed with the pharmacy team and AOM. |
25/10/2024 | 22/10/2024 |
| 3.1 | The pharmacy premises is cluttered and has health and safety risks which does not allow for the suitable delivery of pharmacy services. |
Remove any clutter on the dispensary bench and at the pharmacy premises. Ensure pharmacy team can access to fire assembly point and ensure the garden is well maintained Review the content in the unlocked cabinet located in the shed. Ensure the content is stored securely. Deep clean the consultation room and remove the “unhygienic chairs” in the consultation room. |
25/10/2024 | 22/10/2024 |
Pharmacy inspections
Inspection reports and learning from inspections