Central Pharmacy (1106929) - Improvement action plan

Standard not met	Reason	Action being taken by the Pharmacy	By when	Notification By Pharmacy Improvements Made
1.6	The pharmacy's records cannot always be relied upon, particularly its controlled drug records. The pharmacy has identified discrepancies in its controlled drug registers but it does not take prompt action to investigate them.	• Completion of a CD balance to rectify any discrepancies. • Complete a CD balance check in a timely manner (i.e. if not every week, then at least every fortnight). • SOP’s to be amended accordingly to reflect this.	22/08/2022	25/11/2022
1.1	The pharmacy does not always manage the risks associated with its services, particularly around the management of its controlled drugs. It has written procedures, but these are not complete. And team members do not always follow them and they are not always familiar with what the procedures are.	• All relevant staff members to read the relevant SOP’s and ensure they fully understand the requirements. • The staff will sign the SOP’s to verify they understand the requirements	22/08/2022	25/11/2022
4.3	The pharmacy does not always store its controlled drugs securely. And it does not appropriately control access to its controlled drugs.	• Produce a CD key log • Use a key safe to store CD keys to which only the responsible pharmacist shall have access.	22/08/2022	25/11/2022

Site contents