Well (1086113) - Improvement action plan

The pharmacy does not adequately manage the risks associated with its services. Not all the staff are familiar with the pharmacy's written procedures. Some people have been left without essential medication. And the pharmacy doesn't ensure that routine tasks such as date checking and fridge temperature monitoring are done.

1.1 The pharmacy does not adequately manage the risks associated with its services. Not all the staff are familiar with the pharmacy's written procedures. Some people have been left without essential medication. And the pharmacy doesn't ensure that routine tasks such as date checking and fridge temperature monitoring are done. Check short-dated stock lists recorded on the electronic date checking system against the stock in the dispensary and ensure all OOD stock removed from shelving.

Additional colleagues to be arranged to complete full date check of dispensary and shop floor.

Team meeting to discuss date checking process and re-train colleagues to ensure correct process adhered to at all times (short-dated stock identified, recorded and “use this pack first” alert sticker placed on packaging).

Ensure a date checking rota is in place and adhered to by the colleagues in the future.

AOM to carry out spot check during ongoing store visits.

Team briefed to include additional focus on the date check during the dispensing and accuracy checking procedure in the meantime until full date check of dispensary completed.

Team meeting will include discussion on the importance of fridge temperature monitoring. All the team will be trained on how to complete this and the criteria for escalation to the RP if it is outside of the range, following SOP 18, Appendix 1. Technician will assume responsibility to ensure completion and will delegate the task to a colleague in his absence.
Review of training and competence of current team. Document any required training plan.

All outstanding current team members to read and confirm understanding of SOP’s via e:Expert

Utilise Central Fulfilment to maximise off site dispensing to support workload management.

Review of “Best in Class Processes” to ensure the team are working to the maximum efficiency to support workload management

Full day out of hours working to be completed Sunday 3rd October. 10 working days from receipt of the finalised report Pharmacy Team

The pharmacy does not always maintain its premises appropriately.

Outside alley cleared of vegetation and debris. - completed

Vegetation removed from gutters and gutters repaired to improve drainage. - Completed

Blockage in manhole removed, which had previously caused over-flow.

Outside area to be jet-washed.

Outside staircase to be replaced.
Deep clean to be completed in retail area, dispensary and back of house.

Cleaning rota to be set up and adhered to.

Quote received to carry out repairs to the roof and works to be completed within 6-8 weeks.

Damage ceiling tiles to be replaced following roof repair.