Gilmerton Pharmacy (1042665) - 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 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.

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

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.

Ensure current vacancies are advertised for Pharmacist and Pharmacy Manager and the recruitment process is ongoing.

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.

For an unforeseen closure, the pharmacy team must follow the Business Continuity Plan and follow correct closure process.

Escalate IT issue connecting to the offsite dispensing Hub to enable Pharmacy to use this service.

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 The pharmacy does not have a robust date checking process and it has out-of-date dispensed medicines in retrieval areas.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.