| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not make sure its standard operating procedures are being followed, or that team members are familiar with them. And this increases the risk to people using the pharmacy’s services. |
SOPs have been reviewed, compiled as new and updated according to our working processes. Our employees are currently going through the new SOPs reading understanding and then signing them. Mandatory monthly CD balance checks alongside a quick balance check when a CD is dispensed has been implemented and will be carried out regularly going forward. Baskets that were on the floor waiting to be checked due to lack of space have been removed and a set of shelves have been installed to where these baskets are now placed; waiting for them to be checked. |
17/10/2024 | 07/10/2024 |
| 4.3 | The pharmacy does not always store its medicines securely and in accordance with legislation. And some medicines are stored outside of their original packaging without key information relating to the batch number or expiry date. |
All medicines without adequate expiry dates and batch numbers have been removed from the shelves and staff have been made aware to follow protocols regarding this. MHRA recalls are checked via emails, printed and actioned if necessary, by the pharmacist. Records are kept in a folder in the pharmacy. A new CD cabinet has been bought and installed to ensure there is adequate storage space for methadone and buprenorphine collections |
17/10/2024 | 07/10/2024 |
| 4.2 | The pharmacy does not have robust processes to supply medicines in multi-compartment compliance packs. Pharmacy team members prepare packs without referring to the prescriptions. And packs are stored inappropriately without dispensing labels. |
Revisited and updated our SOP and making sure our staff follow the written processes. Team members have gone through the new SOP regarding compliance packs and have signed the SOPs. Medicines are picked with reference to both prescriptions and labels. Also as noted from your visit we are now keeping the empty boxes for tablets used in compliance aids so that batch numbers and expiry dates are noted by the pharmacist. It has been reiterated on the importance of following the SOP, that the packs should be prepared after reflecting on the prescriptions and checked for any changes, which should be followed up immediately with the surgeries in question. These should be checked and sealed immediately, if immediate checking is not possible they should be sealed and labelled clearly to be checked for a pharmacist in a designated area. Staff have been instructed to add PILs to each medication pack and to add descriptors of tablets/capsules as per SOP. All staff are aware of initialling dispensed by/checked by boxes however they have been reminding of the SOP in place for dispensing practices and to ensure that SOP regarding dispensing is followed |
17/10/2024 | 07/10/2024 |
Pharmacy inspections
Inspection reports and learning from inspections