Stone Pharmacy (1109245) - Improvement action plan

The pharmacy's records are not always adequately maintained. A review of controlled drug (CD) registers identified several inconsistencies including entries made in the wrong register, issues with maintaining and auditing of CD running balances, and a lack of records relating to patient returned CDs. This means the pharmacy may not always be able to account for CDs and it cannot consistently demonstrate safe management of these medicines. In addition, the incorrect prescriber is sometimes recorded on private prescriptions records which could make it difficult to clarify matters in the event of a query.

Designated training for pharmacists and ACT working at Stone Pharmacy- Pharmacist and ACTs on duty will be provided with training on the importance of entering Controlled Drugs (CD), legality of entering and a signed log affirming the training.

Update SOPS relating to CD entries within the pharmacy. This will include requirements to enter CD’s within 24 hours, entering in the correct register and balance check before daily entries are made

Nominating a designated individual who will log discrepancies and actions taken and maintain CD balance checks once a month.


A patient return CD log will be implemented detailing what was returned and when. The returned CD log will also be complimented by a CD destruction log so entries can be accounted for and linked to destruction.

Update SOP training for private prescriptions. All staff will be required to read and sign SOP relating to private prescriptions. A check list will be put up prompting staff members to verify Prescriber name, address and registration number. Spot checks will be carried out by the Pharmacist and management team by taking samples and rectifying errors.

Ongoing monitoring by Superintendent pharmacist. Assessment will be done quarterly to verify implementation of the action plans and if any further support can be provided to ensure GPHC standards are maintained.

Team members do not always use individual NHS smartcards appropriately to access people’s healthcare information. This means the information is being accessed without appropriate controls and audit trails.

Refresher training for staff relating to NHS policy for smart cards. Emphasis on not sharing pins and logging out after use.

SOP policy update to include individual responsibility for card use and consequences of misuse. All staff will be required to read and sign.

Review of smart cards to ensure all staff members working in the branch have individual smart cards to use with the appropriate access.

Ongoing monitoring will be done through system access logs to ensure staff are using smart cards assigned to them and not one smart card across multiple shifts. Non adherences will be investigated and documented.

The pharmacy does not have effective processes to ensure out-of-date medicines are removed from stock and some medicines are not stored in their original packaging or in containers with appropriate labelling. It cannot demonstrate that the temperatures of the medical fridges are appropriately monitored. This means the pharmacy cannot always provide assurance that medicines are in a suitable condition to supply. And it does not properly restrict unauthorised access to some medicines.

Refresher training provided for staff on how to adequately and effectively carry out date-checking of medications held in the pharmacy. Date checking forms implemented for staff to complete when expired medicines identified and disposed of, to maintain an audit trail of tasks carried out.

Medications stored in containers that are not original packaging are to be labelled with relevant information, including expiry dates and batch numbers.

Fridges are monitored and have temperatures recorded daily. If any temperatures taken are outside of required range (2oc – 8oc), actions taken are recorded to demonstrate why medications are still in a suitable condition to supply.

Medicines that have been disposed of are already disposed in yellow disposal bins. However, these were stored unsealed, in the restroom. These unsealed bins have now been removed from the restroom and only sealed bins are stored there