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Pharmacy inspections

Inspection reports and learning from inspections

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Waterloo Pharmacy (1092737) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made
1.1

Pharmacy team members do not always follow written procedures, so tasks are not always completed effectively and some risks associated with pharmacy services are not adequately managed.

We plan to implement a daily checklist, which will be prominently placed. This will include recording the following DAILY.
• Pharmacist RP log
• Pharmacist RP displayed
• Fridge temperature
• Send out all PIL with all MDS trays.
• Record incidents in near miss log immediately.
• Separate and record patient returned medicines appropriately.


Staff Training will be undertaken on SOPs and the following
• Date Checking SOP
• Whistleblowing policy
• GDPR (compliance and understanding)
• Patient returns.
• Monthly recorded staff training.


Safeguarding training has been completed by staff.


Staff member has been enrolled on Buttercups MCA.


Warning stickers for high risk medicine will be ordered.

18/09/2019 27/09/2019
4.3

The pharmacy's stock management procedures are lacking. It does not complete regular date checks, fridge temperature monitoring is sporadic and waste medicines are not segregated and dealt with promptly.

Mentioned above, staff training will be undertaken and reminders in place (staff will be asked to read SOPs again). Paper copy will be used to record temperatures. This will also act as a visual reminder.


High risk alert cards will be produced and used in patient baskets who have been identified as high risk.

18/09/2019 27/09/2019
4.4

The pharmacy cannot demonstrate that it receives and actions drug recalls effectively.

Additional NHS emails have been made for staff, to allow access to the shared NHS pharmacy mailbox.
Training on how to access alerts and how to action them will be provided.

18/09/2019 27/09/2019