Apple Pharmacy (1042651) - Improvement action plan

The pharmacy does not have adequate standard operating procedures for all activities. It does not have audit trails for dispensing. Some activities are delivered by untrained team members.

New SOP for Supply of instalment prescriptions with new procedures to ensure signing of all labels, patient
Identification check and destruction of all
Methadone “traces”( ie the amount that cannot be recovered from each bottle, without allowing this to enter the waste water system) and removal of patient sensitive information from the bottle

New SOP for the production of Monitored dosage trays. This will formalise the existing procedure, and also include necessary amendments to the starting dates of cycles and ensuring secure attachment of the paper backing sheet to the medication tray. An audit trail will to be established to include initials of person checking the prescription (always the resident pharmacist), assembling, and checking the tray.

New dispensing audit trail to be established to include:
Record of all dispensing staff present on each working day (or any part of that day)
Initials of person labelling, assembling and checking each prescription.

Untrained staff members will be restricted to observation of all duties relating to supply of medicines.
Untrained staff members will be enrolled on appropriate training courses within a maximum of two weeks of commencing employment.

The pharmacy does not always protect people's personal information. Some items are not securely disposed of.

As per 1.2 above. The new SOP for instalment dispensing will include procedures to ensure that all items patient confidential details destroyed or disposed of in a confidential waste system.

Some pharmacy team members are carrying out activities that they have not been trained for. And they are not always supervised. The pharmacy does not provide training material or time for developing skills.

Please see 1.1 above regarding untrained staff members.
Supervision of untrained staff will be more vigilant by the regular pharmacist, with support from the more experienced staff.

As per 1.1, new staff members will be enrolled on appropriate training courses sooner, with study time scheduled within the working day.
More experienced staff will have their training needs assessed and time dedicated to training.

The pharmacy does not supply all medicines safely. People are not asked for identification when collecting some medicines, so the wrong medicine or wrong quantity of medicine could be supplied.

As per 1.1, the new SOP for the dispensing of instalment prescriptions will include a check of full name, date of birth and the medication they are expecting to receive.