| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have adequate standard operating procedures for the services it provides and members of the pharmacy team do not follow them. |
All the SOPs are to be reviewed and updated to reflect the current practice within the pharmacy. Obsolete SOPs to be removed (and stored in separate file) and any new SOPs which are required will be added. All staff to read and sign the updated SOPs and adhere to them |
17/01/2020 | 05/02/2020 |
| 1.6 | The pharmacy's responsible pharmacist (RP) record is not always available on the premises and the name of the RP on duty is not always displayed. Records of supplies of unlicensed medicines do not include the patient’s details. 'Headers' are missing from the tops of most of the pages in the CD register. |
Will be communicated to all directors and pharmacists that the RP log must remain on the premises at all times and must be filled on correctly and fully on a daily basis. RP certificate to be displayed correctly at all times. CD register will be audited to ensure each page has the header filled in and communicated to all staff and pharmacists that as each new page is started the header is filled in without fail. |
03/01/2020 | 05/02/2020 |
| 3.3 | The pharmacy is not maintained to an appropriate level of hygiene. |
A deep clean of the pharmacy is to be carried out. All dispensary and consultation room sinks to be cleared out and used only for dispensing purposes. Floor and shelves to be cleaned and stock holding in the front dispensary to be kept to minimum levels to ensure they are kept tidy and presentable. |
03/01/2020 | 05/02/2020 |
| 4.3 | The pharmacy does not effectively manage its stock medicines. It can not provide assurance that the temperature of the medical fridge is appropriately monitored. It does not properly restrict unauthorised access to some medicines and it stores multi-compartment compliance packs which have not been sealed for extended periods. There is no robust date checking procedure and medicines which have passed their expiry date are not always separated from current stock. Some medicines are not stored in their original packaging and have not been appropriately labelled. Some assembled prescriptions are stored on the floor. |
Date checking matrix to be made, full dispensary and shop to be date checked, all out of date medicines to be stored separately and clearly marked until they can be disposed of correctly. All loose medicines that don’t have a batch number (BN) or expiry date to be removed and disposed of and in future any loose or popped medicines to clearly display BN, expiry and date when stored on them. Any assembled medicines to be removed from the floor and reorganise the shelves so these can be stored appropriately until they are collected. |
03/01/2020 | 05/02/2020 |
Pharmacy inspections
Inspection reports and learning from inspections