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Pharmacy inspections

Inspection reports and learning from inspections

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S H Mehta Pharmacy (1042272) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.2

The pharmacy keeps some information about near misses. But it had documented only six near-misses in 2019. The pharmacy keeps some information about dispensing incidents. But, it does not show the root cause or what it has done to manage the risk of the same thing happening again. There is little evidence that pharmacy team members learn from the mistakes or make changes to stop similar errors in the future.

Records will be kept up to date. Staff will be retrained regarding near misses. The dispensers and pharmacist to carry out monthly near- miss reviews. Also carry out monthly audit activities to make sure professional standards are met.
A Root Analysis Tool will be used and staff will be encouraged to see it as a learning opportunity.

17/03/2020 13/03/2020
1.1

The pharmacy doesn't have working instructions in place to support the team members in their roles. And it does not have procedures in place for high-risk activities such as dispensing multi-compartment packs. This means that team members may not be following effective practices to keep services safe.

SOP's and PGD's are there for the staff to refer. Pharmacy staff will be reminded to look at them again. If necessary retrained. Staff to double check high risk items and follow the procedure laid down i.e. to wear gloves for methotrexate and use the counting triangle specially kept for it.

17/03/2020 13/03/2020
2.2

Not all pharmacy team members have a recognised training qualification. Neither are they on a recognised training course relevant to their role. This is not in accordance with GPhC minimum training requirements.

Due to personal reasons this was delayed. All relevant staff have been enrolled on the NPA recognised courses.

17/03/2020 13/03/2020
3.1

There is excessive clutter and waste materials at two of the pharmacy's exit routes. And this presents significant health and safety risks for those that work there.

The exit routes will be cleared of the clutter.

17/03/2020 13/03/2020
4.2

The pharmacy does not provide working instructions. And it does not define its processes and procedures. It does not provide the pharmacy team with information about how to safely provide high-risk services such as multi-compartment compliance device dispensing. And it puts its services at risk of safety incidents.

Processes and procedures will be defined as mentioned in 1.1

17/03/2020 13/03/2020