The Pharmacy (1108932) - Improvement action plan

The pharmacy doesn't identify and manage all the risks associated with providing pharmacy services. It has not implemented suitable procedures to manage its services since the change of ownership. Pharmacy team members have not read the standard operating procedures. And the pharmacy has poor workflow and management, mainly due to issues with the computer system and inadequate planning. There is evidence that things have gone wrong due to the pharmacy not suitably managing its systems and taking limited effective action to resolve these.

All staff have received training on and are continuing to receive training on how to identify risks and to look at any issues that can occur and to notify management of this.

Clinical notes are being made and will continue to be made and actions implemented.

We have a areas for sections such as labelling, dispensing, checking, bagging area, and also have orders area where stock arrives and goes out. Other areas are;
1. Prescription reception area.
2. Consulting rooms/ delivery area

SOPs are signed and read by individual staff depending on their job roles.

The pharmacy team members generally did not understand their roles and responsibilities and the risks in selecting and supplying medicines for people’s prescriptions.

Roles and responsibilities have always been made clear to the new staff members since the job advertisement, job application, interview stage and start of employment. We also follow up by email from head office if we have any queries from staff members and the pharmacy manager is always available if the staff need clarification regarding their role/duties. We have reiterated to all the staff regarding knowledge of their job descriptions, they have responded positively

The pharmacy does not obtain appropriate consent from people to have their medicines supplied from a different pharmacy. And it doesn't have consent from these people to share their personal information as part of this process. The team has limited training and knowledge about protecting people's confidentiality.

All staff members have been informed to do so and we are also checking this when delivering medications also to ask for consent. Any patients who did not want to sign up to our service then we have advised them accordingly and actioned.

There are not enough suitably qualified pharmacy team members to operate the pharmacy safely and effectively. The unqualified team members are receiving limited training. And due to the current working environment there is little time to support these team members. They cannot always find stock or items waiting collection due to their limited knowledge and insufficient experience.

We have doubled the pharmacists in the store through out the month and we have also supplied another trained dispenser staff from our Birmingham cluster. We are also recruiting more staff and have recruited several also

3 qualified staff members are currently on long term sick leave which leaves the new staff to train under supervision of the 2 pharmacists and trained dispenser.

The shop has undergone refit and all shelves have been rearranged in correct manner as the previous layout was not practical. The staff are getting on really well with finding their way around the pharmacy and learning well.

The pharmacy does not manage all its services in a safe and effective way. This includes the failure to supply medicines to people in a timely manner, having limited records and audit trails. It fails to deliver people’s medicines as they expect. And it makes limited or no arrangements to inform them of this. It has poor processes to manage the supply of medicines in multi-compartment compliance packs.

We have had 2 drivers from Redcar come and support the branch delivery service to help urgent medications out to patients. We have a driver who goes out daily to do deliveries between 0800-1000.

Even though we have advised patients that the branch will only be able to provide deliveries on Tuesdays and Thursdays, we are currently doing deliveries 5 days a week to help patients. All supply of medication and compliance packs have been delivered to patients and any patient who wants collection then they will be stopped for delivery.

The pharmacy has only one working computer terminal. And there is evidence of this compromising safety as people are not getting their medicines in time. And no access to the previous computer system is causing difficulties checking previous records.

We had to replace the old system with ProScript (by AAH) as the old system was crashing all the time and we had to keep restarting it. AAH had visited the branch to install 3 computer terminals however the network cables were not working correctly so we ordered new network cable, had it installed and the engineer visited to get the remaining 2 terminals working. The shop has had a new refit

All staff are very happy with the new terminals and user friendly software, they received demonstration from AAH engineer as well and being trained by manager on how to use the system.