| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not adequately identify and manage the risks associated with its services. Team members do not follow the standard operating procedures as this is not part of their induction. This means they have gaps in their knowledge which increases the risks in their ways of working. And this is seen in the way they deliver the pharmacy's services. |
All team members to work through all Standard Operating Procedures and associated guidance relevant to their role and sign the relevant record of competences to confirm understanding. All team members to read the Business Continuity Plan and sign to confirm their understanding. All team members to read the Safeguarding Policy and sign to confirm their understanding. Controlled Drug balance checks to be carried out weekly in line with the CD Standard Operating Procedures. All new colleagues to be enrolled on company induction process. Training rota to be created for all colleagues |
25/03/2022 | 30/03/2022 |
| 1.2 | The pharmacy does not monitor and review the safety and quality of its services. The pharmacy does not have arrangements in place to learn when things go wrong. It does not review dispensing errors and near miss errors so the team are missing learning opportunities. |
Staff to be trained on SaferCare process and on the near miss process. All near misses to be recorded in full and in a timely manner. SaferCare to be completed weekly as per company process. Near misses and patient safety incidents to be reviewed as part of monthly SaferCare process and reviewed with the whole team as a SaferCare briefing to ensure learning opportunities are shared. |
25/03/2022 | 30/03/2022 |
| 1.4 | The pharmacy does not make sustained improvements to the safety and quality of its services following feedback from external stakeholders. It does not evidence any learning from this feedback. |
External feedback to be reviewed and appropriately actioned by the Regional Manager, Field Management support team and the Pharmacy Manager. Learning and/or changes to processes from review of feedback to be documented as part of the SaferCare process. |
25/03/2022 | 30/03/2022 |
| 2.1 | The pharmacy does not have enough suitably trained and skilled team members to deliver all its services safely and effectively. |
Training matrix completed for all colleagues for dispensary tasks and provision of relevant services with sign off for each task when competent. All new colleagues to be enrolled onto the Healthcare Partner course (HCP). All colleagues to be given protected learning time for completion of their HCP within 6 months of date of enrolment. Staffing levels and staff scheduling to be reviewed (as part of right people, right place, right time – RPRPRT) to ensure that the appropriate colleagues are in at the right place at the right time to manage the workload effectively. |
25/03/2022 | 30/03/2022 |
| 2.2 | The pharmacy does not support its inexperienced team members enough with training. So they do not have the skills, competence, or qualifications for their roles and the tasks they carry out. |
LloydsPharmacy Pharmacist double cover support one day per week to support with the training of colleagues. Experienced Non-Pharmacist Pharmacy Manager to support one day per week with training of the current Pharmacy Manager. Experienced dispenser support for two weeks with training of pharmacy colleagues. This will then be reviewed to ensure appropriate competence of the colleagues. |
25/03/2022 | 30/03/2022 |
| 4.2 | The pharmacy doesn't always manage and deliver all of its services safely and effectively, especially its dispensing service. This includes how team members manage dispensing certain types of prescriptions. |
Appoint a Medicines: Care and Review (MCR) champion to support with coaching of team members on MCR. Implementation of robust process for MCR. Review of process for repeat prescriptions. Implementation and training on new process for repeat prescriptions. All team members to be trained on Valproate Pregnancy Prevention Programme guidelines. |
25/03/2022 | 30/03/2022 |
| 4.3 | The pharmacy does not store and manage all its medicines safely due to poor stock control. This includes inappropriate storage of excess stock of returned medicines. And a lack of segregation of usable and obsolete stock in some areas. The pharmacy does not have a robust date checking process and it has out-of-date medicines on its shelves. |
Staff members to be trained on the importance of appropriate storage of medicines and how to handle pharmacy medicine ordering and stock deliveries. Staff members to be trained on process for patient returned medication, including Controlled Drugs. The entire Pharmacy stock, including the stock room area, to be date checked. All short-dated stock will be highlighted, and out-of-date/obsolete medication disposed of in an appropriate manner. Date checking matrix to be completed accordingly and then to be maintained following company process, with the Pharmacy Manager verifying its completion each Quarter. |
25/03/2022 | 30/03/2022 |
| 4.4 | The pharmacy does not have evidence that it deals with medicine recalls appropriately. And the team does not know what to do. So, people may receive medicines that are not fit for purpose. |
Staff members to be trained on medicine recall and alerts process.
|
25/03/2022 | 30/03/2022 |
Pharmacy inspections
Inspection reports and learning from inspections