Croft Shifa Pharmacy (1105188) - Improvement action plan

The pharmacy does not appropriately maintain all of its controlled drug registers in line with requirements. There are discrepancies in a number of registers which have not been investigated in a timely manner.

Final check on all CD’s was conducted on 27th Jan by the Superintendent and another pharmacists to ensure the we are happy with all balances and updated the CD registers.

Report any discrepancies on CD reporting platform after a thorough and final investigation.

Speak to CD accountable officer to see if resetting figures possible as some balances not checked for over a year. New manager has kept up with balances where possible.

Contacted as many suppliers as possible for CD invoices and also looked further all CD invoices and ran a report on RXWeb of all CDs issued to patients and went as far back as possible to ensure our reporting was thorough and as accurate as possible.

Apply for expired CD drug destruction

Introduce superintendent monthly check for all branch to submit so Superintendent can identify any issues and support branches where needed.

Date checking matrix introduced to include CD balances by pharmacist or nominated dispenser in her absence. Errors investigated in timely manner.

Staff to re-read SOP on CD handling, dispensing, storage and recording.

CD liquids to be checked weekly and most common used items. Rest monthly.

Registers closed that have not been used in 6 months to help organise.

Conduct a 6 month CD audit on following SOP and CD balances

Dispose of patient returns with pharmacist.

Organise destruction on CD out of dates.