Edinburgh Pharmacy Foot of the Walk (1042654) - Improvement action plan

The pharmacy does not adequately identify and manage all the risks associated with its services. Team members do not follow all the standard operating procedures as they have not been given adequate time to read and understand them. This means they have gaps in their knowledge which increases the risks in their ways of working. And this is seen in the way they deliver the pharmacy's services. And in not maintaining running stock balances of some medicines requiring safe custody. This means that team members may miss an opportunity to identify potential mistakes.

All team members to work through all Standard Operating Procedures and associated guidance relevant to their role and sign the relevant record of competences to confirm understanding.

All team members to read the Business Continuity Plan and sign to confirm their understanding.

Controlled Drug balance checks to be carried out weekly in line with the CD Standard Operating Procedures.

Controlled drug discrepancies to be investigated by a suitably trained colleague. Any unresolved discrepancies to be reported internally and to Health Board Accountable Officer as per company process.

All team members to be trained on record keeping requirements for Private Prescriptions. Any outstanding Private Prescriptions to be entered into the Private Prescription Register.

The pharmacy does not always have enough suitably trained and skilled team members to manage the workload and deliver all its services safely and effectively.

Staffing levels and staff scheduling to be reviewed (as part of right people, right place, right time – RPRPRT) to ensure that the appropriate colleagues are in at the right place at the right time to manage the workload effectively.

Training matrix completed for all colleagues for dispensary tasks and provision of relevant services with sign off for each task when competent.

All new colleagues to be enrolled onto the Healthcare Partner course (HCP).

All colleagues to be given protected learning time for completion of their HCP within 6 months of date of enrolment.

All colleagues to be given protected learning time to support with ongoing training.

Some people experience barriers to accessing pharmacy services which may prejudice their care. The pharmacy is sometimes closed unexpectedly during normal trading hours, so people cannot access its services. And when the pharmacy is open, people sometimes experience a delay in receiving their medicines.

Review of RPRPRT to include review of opening hours staffing levels to ensure suitably trained colleagues are always present to fulfil core opening hours and therefore allow patients to access all pharmacy services.

Actively recruit and provide support from colleagues in neighbouring pharmacies to ensure the pharmacy have adequate levels of staff to manage their workload safely and effectively

The pharmacy does not store and manage all its medicines safely due to poor stock control, untidiness and lack of fridge temperature monitoring. The pharmacy does not have a robust date checking process and it has out-of-date medicines on its shelves.

Staff members to be trained on the importance of appropriate storage of medicines and how to handle pharmacy medicine ordering, stock counting and stock deliveries.

Pharmacy medicines storage drawers and shelving to be re-organised alphabetically with new identifying labels to be applied to each drawer. Any loose strips of tablets to be segregated and disposed of in appropriate manner. Medicines to be separated by strength and form. Caution stickers to be applied where appropriate to reduce risk.

Dispensary fridge to be reorganised ensuring all high-risk insulin items are clearly separated and all packaging is facing one uniform direction.

Staff members to be trained on fridge temperature monitoring and this must be recorded on all days the pharmacy is open.

Staff members to be trained on process for patient returned medication, including Controlled Drugs.

The entire Pharmacy stock, including the stock room area, to be date checked. All short-dated stock will be highlighted, and out-of-date/obsolete medication disposed of in an appropriate manner.

Date checking matrix to be completed accordingly and then to be maintained following company process, with the Pharmacy Manager verifying its completion each Quarter.