| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy has written procedures in place. But these procedures have not been reviewed recently and there is evidence that not all team members have read and understood them. This means that they may not be working in the safest and most efficient way. |
Review of the SOP to be carried out on the 8th of January 2024 by superintendent. Team members will be given time to review the SOPs over the following 7 working days, taking into account holiday and new staff on boarding. Signing sheet for all team members were in the file, but locum team members hadn’t signed. Time will be made for everyone to re-read. |
26/01/2024 | 15/02/2024 |
| 1.2 | The pharmacy does not have adequate processes in place to identify and manage the risks associated with its services. Team members do not routinely record mistakes they make when dispensing. And they do not undertake regular reviews of errors and incidents. |
RPS near-miss sheet was deployed at the time of the visit but RP on the day was not aware of it. Near-miss sheet re-deployed and located in a more prominent position. Look-alike sound-alike medicines are highlighted via Whatsapp group but this is informal. SP will review near-miss logs every month and will disseminate learnings. It will be recorded if action is required for all team members or an action improvement plan is needed for a specific team member. Urgent issues will be disseminated at pace. |
26/01/2024 | 15/02/2024 |
| 1.6 | The pharmacy does not keep all the records required and does not have good governance procedures for the management of controlled drugs. Records of stock levels of controlled drugs do not always align to the quantity held. |
CD balance reconciliation to be completed. If any stock level discrepancy cannot be accounted for then CD accountable officer will be informed. |
26/01/2024 | 15/02/2024 |
Pharmacy inspections
Inspection reports and learning from inspections