| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.8 | The pharmacy team could not show that they safeguard vulnerable adults and children adequately. |
Remind all the staff of the presence of the safeguarding poster on display Ensure all staff read and sign safeguarding policy |
14/02/2024 | 15/02/2024 |
| 1.6 | The pharmacy team do not keep and adequately maintain all of the records necessary for the safe provision of pharmacy services. |
Introduce regular CD balance checks Provide date checking matrixes to document dates checks are completed Ensure all Specials details are completed in full to include prescriber details Integration of fridge temperature records with the daily RP log |
14/02/2024 | 15/02/2024 |
| 1.1 | The pharmacy did not have adequate procedures in place to ensure that risks were identified and managed. |
Update SOP and have staff sign relevant SOPS to their roles Update Business Continuity Plan – and ensure staff are aware of these plans Complete risk assessments for services provided |
14/02/2024 | 15/02/2024 |
| 1.2 | The pharmacy team did not have any processes in place to monitor the safety and quality of their services. |
Introduction of near miss log and ensure all staff in the dispensing process record near misses and review them on a monthly basis Introduce a separate log for robot corrections made in the process Ensure relevant staff understand how to report a Patient Safety incident and take subsequent action to prevent a similar occurrence |
14/02/2024 | 15/02/2024 |
| 1.7 | The pharmacy team were not trained to protect people's confidential information. |
Display a privacy notice on the premises Display a privacy notice on the website Retrain staff on protecting confidential information |
14/02/2024 | 15/02/2024 |
| 2.2 | The pharmacy team have many staff members who were not appropriately trained and not on an accredited training course. |
All staff in the dispensing process have been enrolled on the appropriate training courses To have all the drivers go through the buttercups delivery driver course Complete training logs for all staff members |
14/02/2024 | 15/02/2024 |
| 2.4 | The pharmacy team did not regularly undergo any ongoing training and development. |
The pharmacy staff will have monthly meetings and a development rota will be in place with regular reviews. Staff to be placed on CPPE courses where appropriate. |
14/02/2024 | 15/02/2024 |
| 3.1 | The pharmacy premises are not clean and adequately maintained. |
A regular weekend regular cleaner is employed once a to provide a deep clean of the site when it is quieter Extra tidy up shifts at the end of the day will also be introduced. |
14/02/2024 | 15/02/2024 |
| 3.2 | The pharmacy does not adequately safeguard people’s private information. |
Contractors have been utilised to look at further soundproofing options and to make some repairs in the pharmacy. The pharmacist prescriber has agreed to seek assurances around the platform he is using for consultations with people |
14/02/2024 | 15/02/2024 |
| 4.2 | The pharmacy team manage services in such a way that presents risks to people. |
A risk assessment is to be in place for the CPCS service highlighting the risks and showing how we have placed measures in place to manage the risks. |
14/02/2024 | 15/02/2024 |
| 4.3 | The pharmacy team stored medicines in a disorganised way, and there are inadequate procedures in place to ensure that they are supplied safely to people. |
Extra shelves have been obtained and we have started the process of installing them to allow for better arrangement of stock SOPs are in the process of being updated and will be signed by all staff |
14/02/2024 | 15/02/2024 |
| 5.3 | The pharmacy team used facilities that could compromise people's private information. |
All Fridge temperatures have been integrated with daily RP logs We have approached the building management to allow us to place a portable sink in the room. If this this is not allowed we will use alcohol gels to provide sanitation. There is also a kitchen area two rooms down which does contain a sink which is available to use The pharmacist prescriber will bring with him a pack which will introduce a clinical waste bin when he is providing consultations. |
14/02/2024 | 15/02/2024 |
Pharmacy inspections
Inspection reports and learning from inspections