| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | Pharmacy team members do not record or analyse their mistakes. And they do not make effective changes to their practices to help make the pharmacy's services safer. |
Following the inspection, the Pharmacist has held a team meeting to ascertain lack of adherence to record keeping. The Pharmacist reiterated that staff must take responsibility in recording their mistakes. Pharmacist has reintroduced daily huddle to ensure compliance with requirement and to discuss changes that may need to be made. All team members agree that reporting errors is vital in preventing errors occurring in the pharmacy. Staff are encouraged to take initiative and provide feedback which will enhance patient safety. As part of the daily huddle, errors are discussed and change is implemented. |
20/09/2024 | 16/10/2024 |
| 1.6 | The pharmacy does not appropriately maintain all of its controlled drug registers in line with requirements. |
Since the inspection, all control drug records are up to date and correct, also stock counts are carried out regularly. Pharmacist to continue to ensure CD entries are now made within the legal timeframe. |
20/09/2024 | 16/10/2024 |
| 2.1 | The pharmacy does not have enough suitably trained staff to make sure that its services and workload are managed safely and effectively. It does not keep up to date with administrative and record keeping tasks. |
Re advertise for suitably trained staff online and in shop window. Consider taking on non-qualified staff members and train to dispenser standard. Consider employing ACT and/or Locum dispenser. Members of staff currently on the dispensers course are supported and strongly encouraged to complete the course and obtain the appropriate certificate. |
20/09/2024 | 28/10/2024 |
| 3.1 | Areas of the pharmacy including the dispensary are cluttered and disorganised. And this could increase the risk of dispensing errors. Boxes are stored on the floor and staircases which present a tripping risk. |
Dispensary has been rearranged to create space to store deliveries once they arrive. The workspaces have been cleared of clutter with areas designated for collections/ deliveries etc. There are deep shelving units in the dispensary which up to now were being used to store fast moving lines. As part of the rearrangements in the dispensary this medication has now been reallocated and the area marked solely for storing medication that have arrived from the wholesalers and are destined for the stock room on the 1st floor. This will free up the floor from deliveries that have arrived creating a clutter free zone. At the staff meeting all the team have agreed on a systematic procedure of removing excess stock from the dispensary and taking it directly to the stockroom without the need to leave it on the stairs. There is a notice in the stairwell reminding staff not to leave any stock on the stairs. All the staff are aware of the need to act promptly in removing excess stock from the dispensary and immediately putting the stock away in the stockroom. As each shelf edge is clearly marked this acts as a reminder to staff that medication needs removing from the dispensary and taken directly to the stock room. Delivery boxes awaiting delivery to patients’ homes are now stored on shelving units. All dispensers are made aware of the arrangement and are asked to comply, therefore reducing the risk of any trip hazards. For the purpose of compliance, I have added the need to tidy the shelves as part of the daily cleaning requirements. |
20/09/2024 | 28/10/2024 |
| 4.1 | 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 always store its medicines securely and in accordance with legislation. And it |
Allocate dispensers specific times/dates to date check. Reiterate importance of logging date checks. Even though there is an expiry date log on the wall, staff are encouraged to add to this list and also remove any items nearing their expiry date. Secondary fridge has removed as temperature data log not reliable. |
20/09/2024 | 16/10/2024 |
Pharmacy inspections
Inspection reports and learning from inspections