| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy’s SOPs have not been reviewed since 2020 and they contain out of date references. Staff read the SOPs when they start working at the pharmacy, but they do not re-read them at regular intervals, and they do not always work in accordance with them. |
All SOPs have been prepared and just require printing and delivering to the pharmacy. All pharmacy staff and pharmacists will be requested to read and sign at the earliest opportunity. SOPs will have a grid highlighting whom the SOP refers to, to aid easy recognition and completing of SOP by the relevant staff. |
30/09/2024 | 07/10/2024 |
| 1.2 | Team members do not effectively review or record their mistakes. And important learning points which are identified following errors are not always shared with the rest of the pharmacy team. This means they miss out on opportunities to learn and improve the way they work. |
Reminder to utilise the near miss log to record all near misses and review on a weekly basis to aid improvements and changes in practice if need be. The improvements identified during near miss reviews and pharmacy incident reviews will be shared with the pharmacy team. |
30/09/2024 | 07/10/2024 |
| 1.6 | The pharmacy does not keep complete and accurate records. This includes the responsible pharmacist record, fridge temperature records, private prescription records, controlled drug registers, and specials records. |
Reminder to staff about the importance of these records being kept up to date at all times. Reminder notices have been in place for RPs to remind them to complete RP Log on a daily basis. Staff reminded to remind the locums as well. All RPs have been reminded again to complete CD entries in their shift and on the day, discouraged to leave for the next RP Fridge temperature to be recorded on the PMR system first thing upon opening to avoid any missed entries |
30/09/2024 | 07/10/2024 |
| 2.2 | The pharmacy does not always support its team members to complete essential training for the roles in which they are working. |
Staff will be encouraged and given time on a monthly basis to carry out personal development to study a new topic area every month, ideas and training tips from sources such as Pharmacy Magazine training modules. Any staff members haven't completed accredited training courses relevant to the roles they are undertaking will be enrolled on accredited training courses. |
30/09/2024 | 07/10/2024 |
Pharmacy inspections
Inspection reports and learning from inspections