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. |
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. |
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 |
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. |
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. |
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 |
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. |
08/11/2021 | 09/11/2021 |