| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not manage all risks. It is not clear which procedures are in use and the pharmacy team have not completed training on these or signed as read and understood. |
All the SOPs will be reviewed, and new ones supplied to reflect our work. Every member of staff will receive training on each SOP, and will sign a sheet to demonstrate they will work to these standards. Each signed sheet will be scanned and stored with the new SOPs electronically, so they can be easily accessed by all staff at any time. |
28/02/2020 | 28/03/2020 |
| 3.1 | There is insufficient space in the pharmacy to safely provide the services currently provided. |
Changing our usual weekend working pattern has already begun to provide one weekend every 4 weeks to tidy, date check and re-arrange all our shelves. |
13/03/2020 | 26/03/2020 |
| 4.3 | The pharmacy does not always store medicines appropriately. It does not routinely check and record fridge temperatures. |
We will purchase a new pharmacy fridge in which to store our refrigeration items. The LEC under bench model would be a good fit in our space. If not already equipped, we will arrange for a remote wireless temperature data logger, that will record and monitor fridge temperatures at regular set times designed to ensure cold chain compliance.. |
28/02/2020 | 28/03/2020 |
| 4.4 | There is no audit trail to provide assurance that all Medicine alerts and recalls are being actioned. |
Every day Pharmoutcomes , and our NHS mail account will be checked for Medicine alerts and recalls by the responsible pharmacist on duty, or ACT if a locum is on duty. Any alerts will be printed out, reviewed and signed by all staff. Suitable action will be taken and recorded on the alert. Alert then stored in box file under pharmacy counter. A message will also be sent to the team via watsapp to notify team members not currently on duty that they should review the alert and sign to record their knowledge of it at their earliest opportunity. An SOP will be supplied and all staff trained to follow this procedure. |
28/02/2020 | 26/03/2020 |
Pharmacy inspections
Inspection reports and learning from inspections