Daynight Pharmacy Ltd (1116805) - Improvement action plan

The pharmacy has written procedures to support safe working. But it doesn't have adequate systems in place to make sure team members have read these and are following them in practice.

Time to be allocated to all staff to read, Understand and sign the SOPS. There will be an audit of the staff to ensure that they have read and understood, and the SOP signature sheet will be countersigned by the RP or Senior Staff.

(TI has now been appointed by the pharmacy to oversee all compliance and other issues with the Superintendent.)

The pharmacy does not fully protect access to people's private information. It doesn't always dispose of confidential waste appropriately. And it does not adequately control the use of smartcards to prevent unauthorised access to NHS information.

Smartcard restriction to holder of smartcard and pin numbers removed from all areas. All staff requiring a smartcard will be set up, but this can take time with the NHS.
Confidential waste – crosscut shredder will be provided and staff huddle to discuss that all confidential waste MUST NOT BE DISPOSED OF inappropriately.

The pharmacy does not always keep stock medicines in appropriately labelled containers. And it cannot show that it always manages medicines requiring safe custody, including patient-returned medicines, appropriately.

The team have been asked to review all split medicines which may contain mixed batches to dispose of these and to ensure in future this does not happen considering the OP dispensing from Jan 2025.

Patients return CD procedures to be reviewed and updated if required and all staff including RP, Locums etc to be trained on the SOP and to ensure compliance. A patient return CD book will be reviewed and staff trained. This CD patient return book will be reviewed regularly to ensure compliance.