Deane Pharmacy (1091193) - Improvement action plan

The pharmacy’s team members do not always follow the written procedures (SOPs) that are available. They do not refer to the prescription when picking and assembling multi-compartment compliance packs to help make sure this process is completed safely.

All staff have received more training on the SOP for Monitored dose system (MDS). All responsible Pharmacist and owners will be monitoring the compliance of the SOP for MDS by all staff members. Since the re-inspection in November 2024, we have taken extra steps and are now making sure staff are following SOP and noting down the date MDS are prepared by the dispenser as per SOP. Continuous monitoring to check staff are following SOP will be carried out by all RP and the owners, the superintendent will be informed of any non-compliance of SOP immediately.
RP has confirmed the dispenser has always without fail signed the dispensed by box for audit trail, all staff have re-visited the SOP and have highlighted on MDS SOP for staff to include the tray sheet in each blister pack to indicate what medication is in each compartment of the MDS before filing them on the shelves. Prescriptions are being printed at the time of picking trays as per SOP. Dispenser to label the Packs and hands the tray sheets to the RP to check at the point of sending them to another branch to be made up as per SOP. At accuracy checking stage of the packs there must be a sheet in each tray to indicate what is in each compartment.