Auckley Pharmacy (1095782) - Improvement action plan

The pharmacy does not always review and monitor the safety and quality of its services appropriately. It does not always act to record mistakes that occur when dispensing medicines. And it does not act in a timely manner to manage discrepancies involving higher-risk medicines and to report these in accordance with its own procedures.

We have had a staff meeting to ensure all mistakes are logged on the near miss error log going forward. The pharmacist will point out the mistake to the staff member involved and a record will be made immediately. The near misses will be reviewed by the pharmacist and discussed with staff every month and any issues identified will be rectified accordingly. Any incidents and near misses will be reported to the NHS via the LFPSE service website and a record will also be kept in the pharmacy.

The pharmacy does not always show how it considers risk when making changes to its services. Its procedures do not reflect the changes it has made to the roles and responsibilities of team members involved in carrying out final accuracy checking tasks. And it does not conduct risk assessments to support it in launching new services safely.

We have an SOP to cover accuracy checking in the pharmacy. The staff member has completed her course and training to carry out checking in the workplace. The pharmacist firstly carries out a clinical and a legality check on all prescriptions to ensure the prescription is suitable for checking by the ACDA. The ACDA's accuracy is randomly audited by the pharmacist. Our SOP for accuracy checking will be updated to describe our pharmacies specific processes and will ensure it informs pharmacists of their responsibilities when working with an ACDA, as they will assume overall responsibility for the ACDA's work. The responsible pharmacist can then decide if they want the ACDA to do accuracy check on their day of work.

We will carry out a risk assessment on the new weight loss service and any future services we intend to provide. This will help us consider and mitigate any additional risks of the services we provide and ensure we are providing these services safely and effectively. Also, monthly audits will be carried out to ensure all paperwork for the service is completed correctly, patient consent, sharing information with GP, medical history and advice provided is being recorded in the notes including for follow up appointments. We only provide services face to face and pharmacists are responsible for calculating patient BMI and checking patient identity which eliminates the risk of unreliable information from the patient.

Pharmacists providing the pharmacy's weight loss service do not always work in accordance with the pharmacy's written instructions. There are gaps in consultation records and although consent is gained to share information with people's GPs about the supply of medicines through the service, the process for sharing this information is not always followed.

We have started making more detailed records of the consultations we have with patients regarding the weight loss service. We now record what we have discussed with the patients, including a more detailed medication history, how to use the medicine, side effects and any advise we have provided. This information is going to be updated on every follow up appointment. we will also carry out a monthly audit on the records being kept and identify any gaps in the consultation records and take action accordingly.

The pharmacy has inadequate management arrangements for storing some of its medicines. It does not store all stock medicines safely in their original packaging. It stores medicines in an untidy manner within the dispensary. And out-of-date medicines are present amongst stock. This increases the risk of a dispensing incident occurring.

We have disposed off any loose medication that was not stored in its original pack. The staff have already tidied up many of the shelves and will maintain this going forward. The shelves have been cleaned and all dates are being checked as the shelves are being tidied. The accuracy checkers double check dates as part of the checking process. As per our SOP all stock will be date checked once every 3 months on a rolling program. Controlled drugs will be date checked more frequently. We will increase the frequency of CD balance checks when we start using the electronic CD register. Routine tidying and cleaning will be done on a daily and weekly basis depending on the task.

The pharmacy doesn’t have suitable measures for measuring liquid medicines. It uses non-standardised plastic measures, without appropriate calibration, to measure higher-risk medicines. And the one standardised glass measuring cylinder available is heavily contaminated with hard water residue and as such is not appropriate for use.

We have ordered calibrated/standardised glass measures for measuring liquids from Alliance healthcare and are just waiting for them to arrive.