| 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 associated with its services. It doesn’t have complete and up-to-date written procedures that reflect the pharmacy’s current practice. This includes how it manages providing supervised doses of medicines to people. This means team members may not always work safely and it may increase the risk of mistakes happening. |
Full complete SOP Review and implement new SOPs for all areas of the pharmacy . Ensure that all team have read and signed these SOPS and SOPs are inline with practices . Build a discipline of team based learning on systems and procedures |
19/09/2023 | 19/09/2023 |
| 1.2 | Pharmacy team members do not have robust arrangements to learn from mistakes. They do not record or analyse their mistakes. And they do not routinely make changes to their practices to help make the pharmacy's services safer. |
A Near Miss Log and Learning outcomes folder to be implemented and regular meetings on learning points to be held with staff to ensure that any near misses are documented and able to be analysed together for betterment of the overall safety of customers |
19/09/2023 | 19/09/2023 |
| 4.3 | The pharmacy does not always store and manage its medicines appropriately. It does not properly label supervised doses of medicines for people. It does not have a robust system for checking expiry dates, and there are out-of-date medicines on the shelves. The pharmacy does not keep all its medicines in packs with batch number and expiry dates, which increases the risk of errors. And it does not always manage controlled drugs effectively. |
Supervised Doses of Bupronophine will be labelled and made ready in boxes the night before and these will be checked and signed by Pharnacist ready for the next day . The date checking matrix will be implemented and kept upto date and ensure that all staff clearly understand the importance of ensuring any medicines that are not in packs must have Batch number and Expiry. It must also ensure that this practice is reduced and kept to a very minimum . The Methameasure and register running balance chekcs matrix will be implemented that SI and RP check this on week by week basis The controlled Drugs returns outstanfing will be destoyed and this practice will be carried out monthly basis going forward |
19/09/2023 | 19/09/2023 |
Pharmacy inspections
Inspection reports and learning from inspections