| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not identify and assess key risks to patient safety. Team members do not always follow the standard written procedures for services and tasks, resulting in disorganised workflow. This includes for the dispensing processes and storage of medicines. |
Area and Regional Manager to conduct a Team Meeting to cover the risks and concerns identified during the inspection. To include SOP and Best in Class processes for: • Prescription Management Full CD audit and balance check to be completed. Patient return CD to be segregated, documented with all available information and denatured. Weekly CD balance checks to be maintained with RP responsible for ensuring it is done by a colleague competent in this role and Senior Area Manager reviewing on regular weekly pharmacy visits. Review of level of training and competence of current team with any required training documented. Area Manager to conduct similar review for pool of relief staff. All outstanding SOPs to be read by staff and understanding confirmed by signing off on e:expert. Newly recruited colleagues to be enrolled on induction process with SOP sign off included as part of this. Minimum of weekly visits from Area Manager to monitor progress and ensure it is maintained. |
09/11/2021 | 09/11/2021 |
| 1.2 | The pharmacy does not monitor and review the safety and quality of its services even though the team is working under pressure. And team members record few mistakes. They do not use this limited information to review the safety of their services. |
Covered in staff briefing (1.1). Briefing will include: Review of Near Miss and PSI Data and sharing of learning with the Team |
09/11/2021 | 09/11/2021 |
| 1.6 | The pharmacy does not always keep accurate records as it is required to do by law. This includes the Responsible Pharmacist record. |
Covered in staff briefing (1.1). Briefing will include advice to staff to prompt RP to sign in. Area Manager to monitor on weekly visits. Aim for greater RP continuity to reduce this risk. |
09/11/2021 | 09/11/2021 |
| 2.1 | The pharmacy does not always have enough suitably qualified and experienced team members who regularly work in the pharmacy. And sometimes team members from other pharmacies support the pharmacy. But they are not always familiar with some of the processes. This means the team struggles to manage the workload. |
Review of staffing levels and skill mix (using staffing and capability assessment document) Completion of staffing rota, matrix and training plan.
AOM to visit at least one day per week to monitor progress and assess workload. Aim to schedule consistent pharmacist cover through liaison with Professional Resourcing Team. Continue recruitment for permanent employed pharmacist manager. |
09/11/2021 | 09/11/2021 |
| 2.2 | Some team members working in the pharmacy do not have the necessary skills and competence for their roles. The pharmacy has not adequately trained them in some dispensing tasks, such as 'hub and spoke' processes and managed repeat dispensing. |
Training time to enable catch up on outstanding SOPs to be provided by enabling, where possible, dedicated time in the pharmacy. Where this is operationally difficult, colleagues will be able to claim payment for training conducted outside of working hours. Support and coach the pharmacy team and relief staff on the Best in Class Processes for Prescription Management. Specific Coaching for RP and ACT to support team in embedding Best in Class processes and a direct open channel of communication to be maintained between Area Manager and RP. |
09/11/2021 | 09/11/2021 |
| 2.5 | Team members raise concerns and provide feedback to improve services. But it is not clear whether this feedback is suitably acted upon by the right people. |
Team to be briefed by Regional Manager on the Freedom To Speak Up Process to use if they believe that any concerns which have been raised by the pharmacy team are not acted on. Area Managers to be briefed by the Regional Manager on the importance of acting on any concerns raised and providing explanations for the actions taken. Area managers to be briefed by Regional Manager on prioritisation e.g. focussing on professional standards when needed rather than retail offers. |
09/11/2021 | 09/11/2021 |
| 3.1 | The pharmacy does not provide a suitable professional healthcare environment. Some areas of the premises are cluttered, untidy and disorganised. |
Cleaning, tidying and de-cluttering - ongoing work with option for Senior AOM to schedule out of hours session if necessary Implementation and maintenance of Best in Class Prescription Management will help prevent a return to this condition and the Area Manger will monitor this on regular visits. |
09/11/2021 | 09/11/2021 |
| 4.2 | The pharmacy does not have adequate control of the way it delivers its services. The workflow is disorganised as the pharmacy is behind completing the workload. And this leads to increased pressure on the delivery of services. |
Training for staff on Best in Class prescription management processes to include use of Central Fulfilment Offsite dispensing as stated above (1.1) Area Manager to coach and support with implementation and monitor maintenance of processes on regular visits. Area Manager to conduct meeting with local surgery to Area Manager to brief team on correct procedure for items owed on prescriptions as per SOP 8. Outstanding owings to be processed daily and any which cannot be fulfilled will be referred to prescriber and / or patient. Team leader to take responsibility for daily check and Area Manager to monitor on pharmacy visits. Palliative Care Service requirements to be reviewed and required stock ordered. Team to be briefed on the requirements of the service and to ensure replacement stock is ordered following dispensing. Area Manager to liaise with Professional Resourcing Team regarding the accreditation of locum pharmacists to provide commissioned NHS services. In the longer term greater continuity of RP as referred to above makes this less of a concern. Team to ensure RPs understand basic function of hand-held devices and if necessary ensure the team support by scanning to the shelf and allowing the RP to focus on checking prescriptions and service provision. Briefing for team on: |
09/11/2021 | 09/11/2021 |
| 4.3 | The pharmacy does not always store and manage its medicines appropriately. This includes separation of medicines in dispensary storage areas, date checking and disposal of returned and obsolete medicines. |
Contents of CD cabinet to be audited, stock balanced, date checked and stored tidily as per Best in Class Process. Patient returns to be documented with all available information and denatured. Authorised Witness to visit on to denature out of dates and in the meantime, these will be balanced, clearly marked and segregated. Area Manager to request work to fix or replace defective CD cabinet lock. Area Manager to brief the team and monitor adherence to the following: • Replacement of “split packs” to the correct storage area to be embedded as a routine task throughout the day and RPs encouraged to contribute to this where possible. |
09/11/2021 | 09/11/2021 |
Pharmacy inspections
Inspection reports and learning from inspections