Bridge Cottage Ltd (1109308) - Improvement action plan

The pharmacy does not manage its risks appropriately. It has not embedded into practice the actions it took to address issues found on previous inspections. For example, there are issues around the safe management of confidential material, storage of medicines, learning from errors, and sharing NHS cards.

Reviewed all previous inspection reports (including Mock reports carried out by directors) and revisited action plans.
Confidential waste is to be monitored more closely and patient returns to be dealt with promptly as a matter of priority. All returns must first be authorised by the RP on duty to ensure no controlled drugs or sharps are being given to be disposed of. – all the team have been briefed. Roles have been assigned to staff so that on opening the pharmacy, at change of pharmacist shift and closing of the pharmacy the locked shed used to store confidential waste is checked to ensure access is restricted at all times.
The temperature in the two rooms used to store medication will be monitored daily and recorded using the opening and closing check in matrix.
Recording near miss and errors more consistently and monthly team briefings to discuss learning and minutes to be recorded.
NHS cards – passwords changed and remain confidential. They are no longer being shared when the Responsible Pharmacist is absent from the premises.

The pharmacy does not always store its medicines appropriately. This could increase the risk that the medicines are not safe for people to use.

The two storage rooms used for large prescription bags and excess medicines are to be monitored daily – temperatures recorded daily at the same time as the fridge temperatures.
All staff have been trained on accurate recording of fridge temperatures, the importance of resetting the fridge and of scenarios including what to do if the temperatures are outside of the required limits.
The dispensary has been cleared of any loose blisters of tablets which have been disposed of safely and also medicines which contained mixed batches – the team have had it reiterated to them that such practice is not acceptable