| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy doesn’t adequately manage all the risks associated with its services. Pharmacy team members don’t have access to up-to-date SOPs that reflect the pharmacy’s current practice. And they do not follow the SOPs that are available. |
The SI will review the available SOP’s and make any amendments if necessary. The staff at the pharmacy will read and sign the revised SOP’s. The SOP’s will be reviewed every 2 years and all the staff will and read and sign the SOP’s. |
25/07/2024 | |
| 1.2 | Pharmacy team members do not have robust arrangements to learn from mistakes. They do not record or analyse their mistakes. And they do not routinely make changes to their practices to help make the pharmacy's services safer. |
Near-miss records will be recorded in the near-miss folder and learning from these records will be carried out. Any mistakes will be reviewed and alterations to working practices will be implemented. |
30/05/2024 | 11/06/2024 |
| 1.6 | The pharmacy does not accurately maintain all of its records. CD registers are not maintained in accordance with current legislation. And running balances are not effectively audited. |
Audit CD registers regular, especially the CDs which are used the most such has methadone. I will also implement a bound CD register for the Methadone. Keep up to the patients returns register. |
25/07/2024 | |
| 4.3 | The pharmacy doesn't store and manage all its medicines appropriately. It does not have effective processes for checking expiry dates or properly monitoring medicines stored in the fridge. And it does not keep all its medicines in the original packs. This increases the risk of supplying medicines to people that are not fit to use. |
Maintain up to expiry date checking of the medicines. Minimum every 4 month expiry date checking. Regularly check fridge temperatures. Ensure all medicines stored on the dispensary shelves are in original packs with expiry dates and batch numbers. Ensure no split medication is stored on the shelves. |
30/05/2024 |
Pharmacy inspections
Inspection reports and learning from inspections