Wellcare Pharmacy (1101446) - Improvement action plan

The pharmacy does not have a robust process to manage the risks of providing medicines in multi-compartment compliance packs.

Dispensers are aware of the SOP’s regarding the mds procedures. Pharmacist and dispensers will review SOP’s to ensure they are fit for purpose. The SOP’s will be monitored diligently by the pharmacist to ensure they are followed. An additional computer PMR labelling system will be introduced on the 1st floor to enable a robust following of the SOP. Staff will be reminded of the consequences of not following the SOP.
Patients who order their own prescriptions will be asked to do so in a timely manner in order to allow the pharmacy staff sufficient time to assemble the multi dose packs.
Both the pharmacist and dispensers will make a concerted effort to make contact with local surgeries to see whether prescriptions can be made available in a timely manner e.g. using repeat dispensing or allowing prescriptions to be ordered at least seven working days in advance.
Dispenser’s will be made aware that any compliance sheet that need alterations must be done in a clear and legible manner and notes made on the reverse of the compliance sheet. Any sheet that is illegible or that may potentially lead to errors must be re-written.
Every ‘monthly’ compliance sheet will have an insert with an indication when the packs are due, when the prescription was ordered and when it is received.
The ‘weekly’ mds patients are ordered on a Monday to be dispensed the following week; which the staff are all aware.

Pharmacy team members dispose of some confidential waste in general waste bins. They do not have robust processes. So, they do not adequately protect people's private information.

All the staff have read and signed the SOP’s regarding patient confidentiality so are aware of the consequences of not protecting patient confidentiality. We will review the SOP’s and I will re-iterate the importance of complying with the SOP. I will endeavor to ensure this is adhered to. I will introduce another shredder on the 1st floor on ensure all staff have immediate access to a shredder.

The pharmacy does not always store and manage its medicines appropriately. It doesn't have a robust process to check for expired medicines. And there is evidence of out-of-date medicines on the shelves. It doesn't always store its medicines in their original containers. So, there is a risk of medicines being supplied to people that are not fit for purpose.

We currently have a 3 month date check rota. Staff are fully aware of the procedure and how to implement it. To ensure a more thorough date checking procedure the date checking will be reduced to once a month on a rotation of staff. The date checking rota will be subdivided into specific areas of the dispensary. An additional date check sheet will be introduced where any medication that is due to go out of date within six months will be added to the list to sure timely removal.