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Pharmacy inspections

Inspection reports and learning from inspections

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Rowlands Pharmacy (1042770) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

The pharmacy does not identify and manage all the risks in the pharmacy. This includes storage of medicines, management of instalment prescriptions, and the management and assembly of multi-compartment compliance packs. Team members do not always follow written processes for the pharmacy's services.

• Ensure relevant SOPs have been read and signed by all colleagues, using Moodle bundles appropriate to job role.
• SOP folder to be set up with colleague SOP completion certificates in place.
• Team training to ensure all colleagues know where to locate the full set of SOPs on company Intranet.
• Team refresher training on company safeguarding process and local contact details to be documented.
• Staff given time to do this in working hours.

08/11/2021 09/11/2021
1.2

The pharmacy does not adequately monitor and review the quality and safety of its services including dispensing accuracy. Team members do not record dispensing errors. And they do not have processes in place to learn from these and reduce the risk of the same mistakes happening again.

• Near Miss recording to be re-established with immediate effect.
• Team refresher training on correct error reporting process.
• A team Monthly Patient Safety Meeting to take place this month with key learnings from the inspection report discussed with team members.
• Branch manager from another branch will visit every Monday from Mid November to complete Monthly Patient Safety Review with team.

08/11/2021 09/11/2021
2.1

The pharmacy does not always have enough suitably qualified and skilled team members to safely deliver its services.

• Colleague rotas to be reviewed by the Regional Leader to ensure an adequate skill mix is maintained through our trading hours. The objective is to ensure there are three staff members in each day 9-6pm
• Planned absence to be controlled to ensure there is no negative impact on branch operational process.
• Additional support being provided by field based team.
• Currently recruiting for a vacancy for 20 hours.

08/11/2021 09/11/2021
2.2

Team members do not always have the appropriate knowledge, skills or competence relevant to their roles. There are some gaps in their knowledge about some processes. This introduces safety risks to people receiving some of the pharmacy's services including medicines supplied by instalment and in multi-compartment compliance packs. The pharmacy does not always provide sufficient supervision and development opportunities for team members.

• Team training needs analysis to be completed, to identify any knowledge gaps and additional training requirements.
• Team member currently completing her NVQ 2 training to continue to receive support from her designated tutor with progress reviews completed in-line with course programme. Additional support is also available through our Professional Qualifications Team at Head office.
• A plan is in place for the team to receive targeted specialist training from the field based coaching team.

08/11/2021 09/11/2021
2.5

The pharmacy does not reassure team members who raise concerns that they are being appropriately dealt with.

• Whistleblowing policy in place which has been read and signed by all team members.
• Team refresher training on correct process to follow in the event a concern is identified.

08/11/2021 09/11/2021
4.2

The pharmacy does not adequately manage all its services safely and effectively. This includes instalment dispensing, and medicines supplied in multi-compartment compliance packs.

• Review of branch governance and process for patient medication supply in multi-compartment compliance packs has been initiated. Initiate individual patient review to ensure each patient has a profile sheet in place which contains an accurate and contemporary list of medication. Pharmacist to review each patient and complete a clinical pharmaceutical assessment
• Review of instalment dispensing service with team refresher training to ensure appropriate governance is in place to record patient supplies.

08/11/2021 09/11/2021
4.3

The pharmacy does not store all medicines safely and securely. Its shelves are untidy, some medicines are not stored alphabetically and are mixed with other medicines. It stores some loose strips of medicines on the dispensary shelves. And some medicines may not be fit for purpose as they have been removed from manufacturers' packaging for an unspecified time.

• Currently undertaking a complete review of all branch stock to ensure medicines are stored safely and eligible for patient supply.
• Any medication identified as unsuitable for supply to be disposed of in designated waste receptacle.
• Team refresher training on appropriate storage conditions of medication
• Date checking and cleaning rotas re-instated with designated date checking and cleaning completed each week in-line with company processes
• Local arrangements being made for controlled drug destruction.

08/11/2021 09/11/2021