Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
---|---|---|---|---|
1.1 | 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 are working under pressure and do not always have time. |
All team members to work through all relevant Standard Operating Procedures which have not been followed. Relevant record of competences to be signed to confirm their understanding.
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. |
21/04/2022 | 29/04/2022 |
1.2 | The pharmacy does not adequately monitor and review the safety and quality of its services. The pharmacy does not have sufficient arrangements in place to learn when things go wrong. It does not review dispensing errors and near miss errors so the team miss learning opportunities to improve patient safety. |
Staff to be trained on SaferCare process and on the near miss process. All near misses to be recorded in full and in a timely manner. SaferCare to be completed weekly as per company process. Near misses and patient safety incidents to be reviewed as part of monthly SaferCare process and reviewed with the whole team as a SaferCare briefing to ensure learning opportunities are shared. |
21/04/2022 | 29/04/2022 |
2.1 | 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. Ensure current vacancies are advertised for Pharmacist and Pharmacy Manager and the recruitment process is ongoing. |
21/04/2022 | 21/04/2022 |
2.2 | The pharmacy does not support its team members enough with training. So they do not have all the skills or competence required to deliver all the pharmacy’s services. And it does not provide training to new team members. |
LloydsPharmacy Pharmacist double cover support one day per week to support with the training of pharmacy colleagues. Swap of inexperienced colleagues with experienced colleague in another LloydsPharmacy to support with training. Experienced Pharmacy Manager to support weekly to ensure managerial tasks are maintained. All new colleagues to be enrolled on company induction process. Training rota to be created for all colleagues Training matrix completed for all colleagues for dispensary tasks and provision of relevant services with sign off for each task when competent. All untrained 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. |
21/04/2022 | 29/04/2022 |
4.1 | 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 and staffing levels to ensure suitably trained colleagues are present to fulfil core opening hours and therefore allow patients to access pharmacy services. Review of Pharmacist Rota to ensure there is RP cover for core opening hours. All staff to read and sign Business Continuity Plan and store closure process.
Escalate IT issue connecting to the offsite dispensing Hub to enable Pharmacy to use this service. |
21/04/2022 | 29/04/2022 |
4.2 | The pharmacy doesn't always manage and deliver all of its services safely and effectively, especially its dispensing service. This includes how team members manage and dispense medicines in multi-compartment compliance packs. |
All team members to read CDS guidance and related SOPs and sign to confirm their understanding. Appoint a CDS champion to support with coaching the team on CDS process. Implementation and training on new process for CDS including the ongoing use of CDS record cards in line with SOP. Review of CDS workload and management of process by CDS champion.
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21/04/2022 | 29/04/2022 |
4.3 | The pharmacy does not store and manage all its medicines appropriately due to poor stock control, and lack of fridge temperature monitoring. The pharmacy does not have a robust date checking process and it has out-of-date dispensed medicines in retrieval areas. |
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 an appropriate manner. Medicines to be separated by strength and form. Caution stickers to be applied where appropriate to reduce risk. Dispensary fridge stock to be written off and disposed of in an appropriate manner due to temperature monitoring not being complete. Dispensary fridge stock to be re-ordered then organised 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 uncollected prescriptions. 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. |
21/04/2022 | 29/04/2022 |