Day Lewis Pharmacy (1106805) - Improvement action plan

The pharmacy does not identify and manage risk well. It is not clear that the pharmacy team learn from their errors.

Regional Pharmacy Manager together with the Regional Support Manager have visited the pharmacy and carried out a comprehensive operations audit and any shortfalls in procedure compliance has been discussed with the local pharmacy team and an action plan put in place to address these.
The local team now record near misses as they arise and record on Pharmoutcomes weekly as dictated by company procedure.
Near misses are to be discussed at monthly team meetings with a view to putting measures in place to reduce the number of errors and near misses being recorded. There is now a clear understanding of the need to record errors and near misses.

The pharmacy team do not have enough staff to provide pharmacy services effectively.

Pharmacy Manager vacancy is still being advertised but regular Day Lewis Support Pharmacists being used to strengthen the local team rather than relying entirely on locums. Manning profiles have been reviewed and appropriate adjustments made to hours employed in order to ensure sufficient staffing levels to provide a safe service offering.

The pharmacy's services are not provided effectively and multiple complaints were made about service provisions during the inspection. The pharmacy team do not regularly provide warning labels on medicines contained with multi-compartment compliance aids.

Better leadership and increased guidance from the field team has improved patient and customer service Whilst MAR charts are not often used for MDS trays, levels at the pharmacy.
backing sheets are used and warning labels are now visible on the backing sheets. PILS are being supplied with each tray before being delivered to the patient.