| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not have a robust process in place to manage and learn from incidents. The team is not always making records of incidents or investigating them appropriately and there is limited evidence of remedial activity or lessons being learnt in response. |
• Improved analysis of near misses and incidents to take place and actions used to inform the monthly patient safety review. • Patient safety review briefing to be undertaken monthly. • Introduce weekly huddles for sharing information and learning from incidents within the pharmacy team |
17/03/2020 | 17/03/2020 |
| 1.1 | The pharmacy is not identifying and managing several risks associated with its services. There is evidence that mistakes have happened that have not been handled appropriately. And due to the lack of staff available, the team is not routinely working in line with the pharmacy's standard operating procedures. |
• Brief pharmacy team members on the importance of recording and learning from near misses. • Brief pharmacy team members on the process and importance for reporting incidents as per company guidance. • Re train any team members on the relevant SOPs identified by the pharmacist as not followed correctly and pharmacist to sign off team members as competent. • Staffing to be reviewed to maintain workload levels in line with Company guidance. |
17/03/2020 | 17/03/2020 |
| 2.1 | The pharmacy does not have enough suitably qualified and skilled staff to provide its services safely and effectively. The current staffing arrangements are insufficient to cope with the workload. Routine tasks are therefore not being completed or undertaken in a timely manner. |
• Workload to be caught up and maintained
• Implement model day • Brief all pharmacy team members on the importance of following model day processes |
17/03/2020 | 01/05/2020 |
| 4.2 | The pharmacy's services are not always being managed and delivered safely or effectively. The team is behind with the workload and the pharmacy cannot show that it is always maintaining effective audit trails about its services. |
• Remind all pharmacy team members of the requirement to use Pharmacist Information Forms (PIF) and their importance • Remind all pharmacy team members of the requirement to initial the pharmacy QUAD stamp.
• Drug alerts to be kept in a designated folder and actions taken confirmed by the responsible pharmacist. • Remind all pharmacy team members on the importance of filing delivery paperwork as per company guidance |
17/03/2020 | 17/03/2020 |
Pharmacy inspections
Inspection reports and learning from inspections