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Pharmacy inspections

Inspection reports and learning from inspections

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Well (1084903) - 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 key risks to patient safety. Team members do not follow written processes for all services and activities. This creates significant risk for services including the supply of medicines in multi-compartment compliance packs.

Area and Regional Manager to conduct a Team Meeting to cover the risks and concerns identified during the inspection. To include SOP and Best in Class processes for:

• Management of MDS
• Controlled Drug record keeping
• Near miss recording
• Near miss analysis
• Patient Safety Incident recording
• Patient Safety Incident review

Full CD audit and balance check to be completed.

Patient return CD to be segregated, documented with all available information and denatured.


Weekly CD balance checks to be maintained. Area Manager reviewing on regular weekly pharmacy visits.


Review of level of training and competence of current team with any required training documented.


All outstanding SOPs to be read by staff and understanding confirmed by signing off on e:expert.

Newly recruited colleagues to be enrolled on induction process with SOP sign off included as part of this.


Cleaning, tidying and de-cluttering - ongoing work with option for Senior AOM to schedule out of hours session if necessary.

Minimum of weekly visits from Area Manager to monitor progress and ensure it is maintained.

09/11/2021 09/11/2021
2.1

The pharmacy does not always have enough team members to safely deliver its services. And the team members it does have are not always suitably experienced and qualified to operate the pharmacy effectively.

Review of staffing levels and skill mix (using staffing and capability assessment document) Completion of staffing rota, matrix and training plan.

Complete 6 weeks forward planning rotas


Maintain 6 weeks forward planning rotas


Assess against workload and identify any shortfalls. Escalate to Senior AOM or ROM.

Recruitment to level indicated by company staffing model plus 39 additional hours shared across both pharmacies to provide sufficient continuity in the event of any unplanned absence and to enable time for catching up on workload, tidying and training.


Utilise available relief work force where needed and where possible.

Senior AOM to visit at least one day per week to monitor progress and assess workload.

Aim to schedule consistent pharmacist cover through liaison with Professional Resourcing Team. Continue recruitment process for permanent employed pharmacist manager.


Training time to enable catch up on outstanding SOPs to be provided by enabling, where possible, dedicated time in the pharmacy. Where this is operationally difficult, colleagues will be able to claim payment for training conducted outside of working hours.

09/11/2021 09/11/2021
4.2

The pharmacy does not always plan and manage all its services safely and effectively. This includes the assembly and supply of multi-compartment compliance packs.

Conduct meeting with local surgery to
• Agree uniformity of communication from surgery and pharmacy about timescales for prescribing and dispensing processes for repeat prescriptions.
• Establish better collaborative working to ensure expeditious ways of resolving queries from both sides.

MDS SOP and Best in Class process to be read by all staff.

Briefing from Area Manager on MDS process with focus on the importance of correct and accurate Record Keeping with particular focus on the need for:
• Clear unambiguous record sheets.
• Clear, indelible alterations and where necessary replacement of documents following changes.
• Use of workload tracker which indicates completion of every stage up to and including supply.
• Review of workload tracker to ensure no stages including supply are missed and not acted on.

09/11/2021 09/11/2021