| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not routinely assess key risks to patient safety from its activities and services. And it cannot provide the necessary assurance that services are as safe as they need to be. |
The pharmacy has introduced near-miss recording. And includes an end of month review to identify patterns and trends. The pharmacy records dispensing incidents on the PMR. And carries out a root cause analysis to identify areas for improvement |
12/09/2019 | 03/09/2019 |
| 1.2 | The pharmacy had not defined risk management procedures. And team members are not trained to systematically review their processes and procedures. The pharmacy does not keep records of near-misses, dispensing incidents or complaints. And it is unable to show where it has improved its services when things have gone wrong. This means that risks are not managed. And puts people at risk of unsafe services. |
The pharmacy has reviewed and updated the SOPs. And a new review date has been added for the future. The SOPs have been read and signed by staff. |
12/09/2019 | 03/09/2019 |
| 1.6 | The pharmacy does not keep all of the records it needs to by law. It does not manage high-risk medicines according to best practices. And it does not keep registers of high-risk medicines up to date. This means the pharmacy cannot provide assurance that people have received the correct medication. |
Processes being reviewed regularly and improvements discussed with staff at staff meetings. Introduction of methameasure system (install completed 30 July 2019), RP signs out at the end of the working day or when they leave. PGDs authorisation sheets are held on site. |
12/09/2019 | 03/09/2019 |
| 4.2 | The pharmacy follows out-of-date working instructions. And does not provide its services according to best practice. This means that services are not as safe as they need to be. And increases the risk of things going wrong. |
The pharmacy has reviewed and updated the SOPs. And a new review date has been added for the future. The SOPs have been read and signed by staff. |
12/09/2019 | 03/09/2019 |
| 4.3 | The pharmacy does not have the necessary controls in place to manage the medicines that its keeps. This means that medicines may not be safe to use. |
Ensure that when assigned staff are checking stock expiry that they are to be uninterrupted. Dates are already checked monthly, will be protecting staff’s time when checking in future to prevent packs being missed. Contacted FMD equipment supplier and awaiting an install date. |
12/09/2019 | 03/09/2019 |
| 4.4 | The pharmacy does not receive safety information about medicines that are unsafe for use. And it cannot provide assurance that it removes affected medicines from stock. This means that unsafe medicines may still be in use. And there is a risk that these may be given to people. |
In addition to staff checking for affected stock, MHRA reports are printed and will be kept for future reference. |
12/09/2019 | 03/09/2019 |
| 5.2 | The pharmacy cannot provide assurance that all equipment is safe to use and fit for purpose. |
Computers and methameasure equipment are all new or managed as part of contract with suppliers. Pump used prior to methameasure install to be sent for scheduled service. |
12/09/2019 | 03/09/2019 |
Pharmacy inspections
Inspection reports and learning from inspections