Keyworth Pharmacy (1093263) - Improvement action plan

The pharmacy has a range of written procedures to support it in managing its private clinic services. But there are no accompanying formal risk assessments to show any due diligence checks on the third-party companies it procures equipment from when introducing novel services. And to show how the pharmacy identifies and manages risk when conducting these services, particularly when some tasks are delegated to team members other than the prescriber.

Complete and sign service-specific risk assessments for all clinic services.

Attach them to the clinic SOP set and ensure they are accessible to all staff.

The pharmacy does not make and maintain records as required. Responsible pharmacists do not always complete records to show when they have finished their shift. And team members do not always make a record of all required information when completing the Prescription Only Medicine (POM) Register, including full details of the prescriber and the patient's address. And on occasions an entry in the POM register is missing when medicines are not entered onto the patient medication record appropriately.

Retrain all pharmacists on completing RP log entries.

Implement a start/end-of-shift RP checklist.

Retrain staff on legal requirements for POM entries.

Introduce a weekly POM Register check for completeness.

Ensure all medicines prescribed and supplied through clinic services are suitably labelled and recorded in the POM register with prescriber details, patient address, product name, strength, form, quantity, batch number and expiry.

The prescriber does not consistently document the information discussed during consultations, including the rationale for prescribing decisions. This limits the ability to demonstrate that appropriate checks have been carried out to ensure people understand how to use their medicines safely and know what follow up is required. And the current process for prescribing does not ensure that a legally valid prescription is produced for dispensing.

Update prescribing workflow to ensure a legally valid private prescription is produced for every supply.

Retrain prescriber and staff on the updated process.

Update clinic consultation template to include: medical history, current medicines, allergies, adverse effects, safety-netting advice, and follow-up requirements.

Introduce a mandatory “clinical rationale” section within the consultation record.

Retrain prescriber and staff on completing the updated template.

The pharmacy does not make frequent checks to ensure all products requiring cold storage are stored at the correct temperature. There are regular missing entries for the fridge temperature records and no record is in place for one of the pharmacy's fridges.

Implement once daily fridge temperature recording for all fridges.

Add missing fridge to log sheet.

Audit compliance Monthly.

The pharmacy does not have appropriate safeguards in place when providing its private clinic services. Not all pharmacy professionals have immediate access to its written procedures for these services to refer to. The pharmacy provides prescribing services without producing valid private prescriptions. And there is a lack of visibility of delegated responsibilities for some services, particularly for weight loss services. Furthermore, incomplete consultation records means pharmacy professionals do not always have the ability to check previous records for people returning for further treatments to ensure continued treatment remains safe.

Make all clinic SOPs digitally and physically accessible to all pharmacy professionals.

Record staff training for all clinic SOPs and retain evidence that staff have read and understood them.

Create a delegation matrix for clinic tasks, including weight-loss services.

Ensure process includes reviewing previous consultation notes before prescribing or administering treatments.

Reinforce process to ensure a valid private prescription is produced for every clinic treatment.