| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy doesn’t adequately manage all the risks with its services. The pharmacy doesn’t have complete and up-to-date written procedures that reflect the pharmacy’s current practice. This includes the management of near miss errors and dispensing incidents. And pharmacy team members rarely use the procedures. |
1. A process of reviewing and updating all pharmacy SOPs to be undertaken 2. SOP for dispensing errors and near misses to be updated by 31st December 2021 This will encourage Route Cause Analysis and reporting via the Learning From Patient Safety Events service website ( LFPSE) . All staff to read and sign the updated SOP by 31st January 2022. 3. New SOP to audit staff compliance with pharmacy SOPs to be developed and deployed by 31st January 2022. 4. All staff to undertake the Virtual Outcomes training module: ‘How to reduce dispensing errors’ by 31st January 2022. |
14/01/2022 | 25/01/2022 |
| 1.6 | The pharmacy does not keep all the necessary records required by law. The records it does keep are also not adequate to ensure the safety of the services it provides. |
1. New locum checklist to be produced 2. SOP for Controlled Drug management to be updated by 31st December 2021. Will include weekly balance check and reporting detail for |
14/01/2022 | 13/01/2022 |
| 1.8 | The pharmacy does not have a suitable procedure to deal with safeguarding concerns. Some pharmacy team members are not appropriately trained and do not demonstrate the required knowledge to be able to suitably identify and help a vulnerable person. |
1. All staff to undertake the Virtual Outcomes training module: ‘Safeguarding’ by 31st January 2022. 2. SOP for safeguarding to be updated by 31st December 2021. This will include local contact and escalation detail. All staff to read and sign the updated SOP by 31st January 2022. |
14/01/2022 | 25/01/2022 |
| 4.3 | The pharmacy does not have an adequately robust process for managing the storage of its medicines and for checking expiry dates. And there is evidence of out-of-date medicines. The pharmacy does not always keep its medicines in the original packs and label these properly. It doesn’t store medicines requiring safe storage in accordance with the law. So, there is a risk the pharmacy may supply medicines that are not fit for purpose. |
1. New SOP for the date checking of all stock to be in place and read and signed by all pharmacy staff by 31st December 2021. 2. A full review of the MDS dispensing process to be undertaken and an updated SOP put in place and read and signed by all staff involved in MDS preparation by 31st January 2022. |
14/01/2022 | 25/01/2022 |
Pharmacy inspections
Inspection reports and learning from inspections