| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not routinely assess key risks to patient safety from its activities and services. The pharmacy has not felt the benefit of risk assessments carried out by the head office team on the impact of significant changes in the local area which led to an increased workload. Team members do not always follow the pharmacy’s written procedures which state who should complete each task and how it should be done. |
The Operations team at head office routinely assess the impact of local changes for example closures of local pharmacies. It is currently a very unpredictable market compounded with the workforce shortages. The pharmacy has been allocated additional hours to manage the workload. They are currently recruiting for 2 part-time vacancies. 1 of which has been filled and a colleague is due to start. 1 of the other colleagues will be completing the MCA course shortly and will start the dispenser course. In total there will be 5 part-time colleagues to cover the 100 hours. The team will have read/signed the electronic training record card for each of the SOPs relevant to their job role. |
25/04/2023 | 20/04/2023 |
| 1.2 | Team members do not routinely record and review mistakes they make. This means that there is limited opportunity to learn from mistakes and prevent them from happening again in the future. |
The team have been briefed on the requirement to record near misses in the near miss log as well as the importance of and process of reporting errors. |
25/04/2023 | 20/04/2023 |
| 2.1 | The pharmacy does not have enough team members to manage its workload safely. The pharmacist is regularly left to work alone in the pharmacy, which has led to mistakes being made. |
Vacancies had been put out to backfill the colleagues that had left the department. We were using locum dispensers to support the colleagues in the pharmacy and since the inspection we have successfully recruited a colleague into the pharmacy, with another colleague set to join in the coming weeks. We have not found any evidence that pharmacists working alone has led to mistakes. |
25/04/2023 | 20/04/2023 |
| 2.2 | Pharmacy team members carry out tasks that they have not received appropriate training for. And they have not been registered on the required courses. |
All colleagues will have been signed on to a training course and have a buddy manager who will support with the completion. |
25/04/2023 | 20/04/2023 |
| 2.5 | The pharmacy team do not feel that they are listened to when they raise concerns about the pharmacy. They work under considerable pressure and stress. |
Listening sessions have been held with the employed pharmacy colleagues and concerns have been addressed: |
25/04/2023 | 20/04/2023 |
| 4.3 | Expired medicines are not routinely removed from stock and there is a risk that these may be supplied to people. The pharmacy does not monitor the temperature of its fridge meaning that it may not be aware when cold-chain medicines are stored outside the required temperature range. |
The team have been briefed on our daily Safe and Legal check process which encompasses the daily monitoring of fridge temperature. |
25/04/2023 | 20/04/2023 |
| 4.4 | The pharmacy does not have a robust system in place to ensure that recalls of defective medicines are actioned appropriately. |
There is a colleague on duty in store who has access to the platform and will bring any pharmacy specific recalls to the pharmacy to be actioned. The team in the pharmacy will be retrained on our SOP around handling emergency product withdrawals. |
25/04/2023 | 20/04/2023 |
Pharmacy inspections
Inspection reports and learning from inspections