| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have adequate standard operating procedures for the services it provides and members of the pharmacy team do not follow them. |
New SOPs are being finalised in electronic version and will be printed. The pharmacy team will be trained in the new SOPs and compliance with the SOPs monitored. Any members of the team who do not follow the SOPs will be disciplined and retrained. |
17/09/2019 | 17/10/2019 |
| 1.2 | The pharmacy does not report and learn from near misses and dispensing incidents. |
The pharmacy will clearly set out new reporting procedures. A dispensing error record book is located in the dispensary and pharmacy team members will record any such incidents and learn from their mistakes. The team will also be encouraged to record any near misses so that they can learn from these too. |
17/09/2019 | 17/10/2019 |
| 1.7 | The pharmacy does not adequately separate and destroy confidential waste and does not store confidential information securely. |
The pharmacy superintendent will investigate and review the teams methods of separating and destroying confidential waste and storage of confidential information and provide staff re-training for any omissions. |
17/09/2019 | 17/10/2019 |
| 2.2 | Some members of the pharmacy team are not qualified or appropriately trained for the activities they carry out. |
The medicine counter assistants will not carry out dispensing activities until they have commenced an accredited training course in dispensing. |
17/09/2019 | 17/10/2019 |
| 4.2 | The pharmacy delivers medicines without adequate control and safeguards. The pharmacy assembles and checks multi-compartment devices without reliable audit trails and stores them unlabelled for extended periods. |
The pharmacy will introduce safeguards into the delivery service including an audit trail and signatures from the recipient where possible. This is to be reflected in the SOP. The pharmacy will introduce more reliable audit trails for multi-compartment devices and fully label them at the time they are assembled and only once the prescription has been received. This is to be reflected in the SOP. |
17/09/2019 | 17/10/2019 |
| 4.3 | The pharmacy can not provide assurance that the temperature of the medical fridge is appropriately monitored. It does not properly restrict unauthorised access to some medicines and it has not taken steps to comply with the Falsified medicines directive (FMD). |
The pharmacy will obtain a new specialist pharmacy fridge and the pharmacy team will record the fridge temperature manually. Appropriate steps are being taken to restrict unauthorised access to some medicines. The pharmacy have registered with Securemed and Pharmascanner and will work to deploy FMD as soon as possible. |
17/09/2019 | 17/10/2019 |
Pharmacy inspections
Inspection reports and learning from inspections