| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not manage all risks. It does not have standard operating procedures. This means mistakes could happen. |
Standard Operating Procedures have now been updated and staff are in the process of reading /understanding & implementing them. |
12/06/2019 | 09/07/2019 |
| 1.2 | The pharmacy does not record or review mistakes. So, it is missing an opportunity to learn from these and avoid the same mistakes happening again. |
Folder has been filled with near miss/error log sheets to be completed by all Pharmacy staff when mistakes are made. This can be reviewed monthly to look for patterns and trends and adapt if needed. |
12/06/2019 | 09/07/2019 |
| 1.6 | Pharmacists do not complete the responsible pharmacist record accurately. This is a legal need. The inaccurate entries could shift responsibility to the wrong person. |
Responsible Pharmacist log book in place in dispensary to be fully completed by all Pharmacists with start and finish time. |
12/06/2019 | 09/07/2019 |
| 1.7 | The pharmacy does not always protect people's personal information. |
Two screens will be sourced that can be pulled to protect names on bag labels for prescriptions waiting to be collected if a member of the public needs a consultation to the rear of the shop. A shredder will be purchased for confidential waste. |
12/06/2019 | 09/07/2019 |
| 2.2 | The pharmacy does not ensure that all team members are suitably trained and qualified for their role. |
The current dispensing assistant will endeavour to complete her training as soon as possible. Time will be given on the job to help her complete this when time allows. |
12/06/2019 | 09/07/2019 |
| 2.4 | The pharmacy does not learn from previous feedback such as inspection reports. It does not share information and incidents within the wider organisation to learn and improve services. |
Going forward we will regularly share branch information on important matters that arise so we can prevent these incidents in the other branches. |
12/06/2019 | 09/07/2019 |
| 3.1 | The pharmacy does not have potable running water. The only sink is in the toilet area. Pharmacy team members wash cups and medicine measures in this area and then store them here. |
Bottled water will now be used to make up medication. When opened the bottle will be labelled with the date of opening and discarded within 48hrs. |
12/06/2019 | 09/07/2019 |
| 3.2 | The premises does not protect people's information. Team members have private conversations with people on the shop floor, and in an area where personal information is visible. |
See 1.7. Staff have been made aware that private conversations/sensitive information must be done with the patient to the rear of the shop if needed or wait until shop is empty to have that conversation. It is not a busy shop. This is the next shop due a refit within the group. I am very aware that a consulting room is needed. |
12/06/2019 | 09/07/2019 |
| 4.2 | There is a risk that services may be unsafe as there are no standard operating procedures in place. The pharmacy team members do not always give people the extra information needed with some medicines. |
See 1.1 |
12/06/2019 | 09/07/2019 |
| 4.3 | The pharmacy does not store all medicines properly. And it does not routinely check expiry dates. So, it could supply out of date medicines. |
Date Checking/Cleaning rota sheets are to be implemented & completed. Any loose medication on shelves will be destroyed. |
12/06/2019 | 09/07/2019 |
| 5.1 | The pharmacy does not have equipment to destroy confidential waste. So, people's personal information could be seen within general waste. |
Cross cut shredder to be purchased & used to destroy confidential waste. |
12/06/2019 | 09/07/2019 |
Pharmacy inspections
Inspection reports and learning from inspections