| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.6 | The pharmacy does not maintain all of its records accurately. And it does not enter information into records in a timely manner as required by law. |
Archive divider implemented to separate SOPs that are not currently relevant and may confuse newer members of the pharmacy team. Daily checklist implemented whereby all CD prescriptions and invoices should be actioned by end of day. Supervised prescriptions to only be given out following records of instalment collection. The same practice of entry before giving out to be applied to all Controlled Drugs. Regular controlled drug balance check to be carried out internally. And External GPhC registered locum pharmacy technician to carry out a balance check alongside these checks (planned schedule of checks provided to inspector). Monthly checklist created whereby legally required entries for unlicenced medicines and private prescriptions are audited. Provision in monthly checklist for audit of near miss log. Basket of near misses created so that the workflow dynamic is not interrupted by recording near misses. |
04/01/2024 | 07/01/2024 |
| 3.1 | The pharmacy’s work benches, and some floor areas are cluttered. This increases the risk of an adverse event occurring. And it leads to team members working in a disorganised way. |
Additional shelving to be fitted to the rear of the pharmacy. Monthly removal of prescriptions older than four weeks to be carried out to improve space. Provision in weekly checklist for audit of cleaning rota, clearing of work benches of part assembled medicines and clearance of floor areas. |
04/01/2024 | 09/01/2024 |
| 4.3 | The pharmacy does not store and manage all its medicines in a safe manner. It does not always make appropriate checks to ensure medicines with a shortened expiry date once opened remain safe to supply. |
Provision on monthly checklist for audit of date checking and fridge cleaning logs. Staff instructed to include year of opening as well as day and month on opened medication. Risk assessment carried out regarding out of pack dispensing for patient taking Sodium Valproate. Provision in monthly checklist for scan of dispensary shelves to ensure all stock in original packaging and with expiry date and batch number clearly presented. Provision in monthly checklist for check of out-of-date CD prescriptions and that procedure of using clear bags and highlighting expiry date followed. Evidence of MHRA alert checks and consequent action to be logged as discussed in visit. Audit that this being followed every month. Audit of PMR recording of prescription interventions to be carried out monthly. First intervention has already been recorded. |
04/01/2024 | 07/01/2024 |
Pharmacy inspections
Inspection reports and learning from inspections