Well (1084903) - Improvement action plan

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.

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.