Wellcare Pharmacy (1101446) - Improvement action plan

The pharmacy doesn’t adequately manage all the risks associated with its services, especially when providing people with medicines in multi-compartment compliance packs. The pharmacy does not have written procedures available to help team members manage some key risks. And team members do not always read or follow the procedures that are available.

Updated written SOP in place. Clear and concise steps in the SOP which are easy to follow. At various stages of the SOP there are risk identified, with solutions, should any problem arise during the dispensing of MDS.
Specifically mentioned in the SOP regarding turnaround times of MDS to allow for time management.
Four weekly MDS cycle to be divided evenly to ensure workload is even across four weeks.
Discussed individually with each member of staff involved with MDS.
Team member to read, understand and sign SOP.
Introduce SOP to 1st floor dispensary to act as aide memoir.
Conduct audits to encourage SOP is followed. encourage dispensing staff to actively get involved in managing the SOP should gaps are identified that may mean the SOP need revising.

The pharmacy does not appropriately maintain all its records. And it does not accurately record and report controlled drug related incidents.

Updated MDS SOP to include a section on how to record details of conversations on the PMR.
Updated SOP regarding dispensing Controlled drugs into MDS.
Dispensing staff made aware of the importance of informing the RP should a stock CD2 need to be destroyed and how to report/record.
Dispensing staff introduced to CD 2 reporting website and its purpose.

The pharmacy is cluttered and untidy. Pharmacy team members do not make effective use of the limited space available. And this introduces unnecessary risks.

Open the office to use as excess stock room. This will free up more space in the upstairs dispensary for workspace.
Daily delivery of medication to be sent to the stock room in a timely manner.
As above, keep split packs to a minimum with regular check/audits of split pack shelf.
Posters in the dispensary with matrix signed and dated by staff to confirm Split pack shelf is reconciled. encourage dispensing staff to minimise split packs thus encouraging safe dispensing practice. Checklist on display to ensure split packs are reconciled and kept to a minimum.
Spot checks to ensure compliance.
Ensure the LASA methodology is incorporated in the 1st floor dispensary.
Posters in the stairwell to ensure stock is not left there.

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. The pharmacy does not routinely provide people with the necessary information to help them take their medicines safely. So, there is a risk of medicines being supplied to people that are not fit to use and that they may not know how to use properly.

Set clear expectations. Dispensing staff should know what is expected of them and to have a sense of accountability. Regulatory checklist on display showing date checking to be carried out by the team. allocate a rota to monitor this effectively.
Update SOP for Date checking. Introduce shelf edging for each department of the dispensary with its own date checking log. Also as above for split pack shelf.

As SI, my responsibility will be to carry out regular checks to encourage and ensure team compliance through use of a regulatory checklist on display in all departments showing daily, weekly and monthly checks.
I would conduct a monthly audit and ad-hoc spot check to check on compliance with SOP.
These to include:

-patient safety
-Medicine storage
-Date checking
-Cleaning
-Health and safety
-record keeping

Check the signed and dated matrix at the end of each week.
Sign off the audit sheet once per month to confirm it has been completed and SOP followed.