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Pharmacy inspections

Inspection reports and learning from inspections

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Sciensus Pharma Services Limited (1084907) - Improvement action plan

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

Healthcare at Home doesn’t fully identify and mitigate the risks to ensure the continued safe and effective delivery of its services. It doesn't always have robust contingency planning, particularly when introducing and implementing changes such as information technology (IT) system updates. This means people don't always receive the delivery of their medicines before they miss a dose. And this may cause them harm.

Reviewing Healthcare at Home change control process to ensure fit for purpose and explicitly review risk management for proposed change. This includes lessons learned from recent IT upgrade including;
- Continual monitoring of failed deliveries and missed doses
- Further follow up with a Healthcare Professional any patient who has a failed delivery beyond 5 days or misses a dose of medication.
- Daily and trended review of any patients who have missed a dose
- Updated staff training and monitoring of compliance
- Proactive external communication of any change
- Piloting and phased approach to change
- Scenario and pathway planning for system failures
- Enhanced continuity planning including different ways for patients to contact Healthcare at Home including text messaging, emailing, two way chat and development of an App.
- Continuous review of success and impact including auditing

28/04/2021 24/04/2021

Some of the information Healthcare at Home holds about the medicines people have at home is not accurate. And it doesn't have suitable arrangements in place to ensure changes to its systems and processes do not impact on the safe and effective delivery of services. This means there is a risk that people experience delays to the receipt of their medicines and may miss their prescribed doses.

Reviewed and changed process to ensure patients supply of medicines are maintained. This includes process for rescheduling any failed deliveries and monitoring to ensure the newly arranged delivery date is close as possible to original delivery date. Any missed doses of medication are reviewed by a Healthcare Professional and monitored daily. System changes will also follow the same learns as outlined in 1.1

Additional focus ensuring patients receive next delivery whilst still having some medication at home. Buffer stock levels are set as per Trust requirements and must be updated if more or less stock is used e.g. dose change or patient problems with medicines use e.g. faulty product. Healthcare at Home supply quantities as per prescription so patient homes are not overfilled due to clinical risk and cost. Buffer stock levels are also relative to each individual patients understanding. To aid accurate understanding of buffer stock, Healthcare at Home have provided further training with staff, a system change to aid calculation of stock in line with delivery date. Updated patient guidance on signposting and further patient training on medication stock checks with Healthcare Professionals. Enhanced continuity planning including different ways for patients to contact Healthcare at Home including text messaging, emailing, two way chat and development of an App.

28/04/2021 24/04/2021