Badham Pharmacy Ltd (1116985) - Improvement action plan

The pharmacy's records are not always maintained in line with legal requirements. This includes records of private prescriptions and controlled drugs. The pharmacy cannot demonstrate that discrepancies in the balances for the latter, when highlighted or identified are appropriately investigated, reported or annotated in the registers.

I have reminded all branches that the correct GP must be recorded on the records held for all private prescriptions, to ensure compliance with the legal requirements.

The branch has always checked the running balances for all CD;s every Saturday as a matter of process. I have reminded the team that any discrepancy that cannot be resolved must be reported to me within 7 days . If the error cannot be resolved, then I will report the incident to the Accountable Officer and make the required entry on CR Reporting.

The pharmacy does not have enough suitably qualified and skilled staff to provide its services safely and effectively. The current staffing arrangements are insufficient to fully cope with the workload, and
routine tasks are not being completed or undertaken in a timely manner.

We are adverting internally for our staff who work at other branches, to see if they would like to cover shifts at St Pauls, this has had some effect with two members of staff stepping forward. A few months ago, we increased the hourly rate of any dispensing technician or dispensing assistant who works in the evening to reflect the unsociable hours the pharmacy opens to reward the staff for working until 10pm.
We have in recent weeks employed an agency technician full time to help at the branch.
We have offered shifts to two previous technicians, and they have supported the branch for evening shifts and weekend support
Finally, the directors have supported the branch, with Peter and Linda Badham both working in the branch. Some weeks we cover three late shifts to 10 pm . In addition, Linda Badham has covered many mornings shifts, working up to 30 hours a week at the pharmacy.

Pharmacy services are not provided from an environment that is appropriate for the provision of healthcare services. The pharmacy is not being cleaned regularly, most of the pharmacy is extremely cluttered, and the dispensary is unable to support the pharmacy's current volume of dispensing.

A revised cleaning and date checking rota has been set up, whereby one section of the dispensary will be cleaned, and date checked every Saturday. Excess stock has been returned to the warehouse.
The first-floor weekly tray dispensing area has been commissioned with stock held in the first floor, again to ease pressure on space I the main dispensary.

The pharmacy is not managing its medicines in a satisfactory way. This compromises the safe supply of medicines and medical devices. The pharmacy cannot demonstrate that its team members have been routinely checking medicines for expiry and medicines requiring refrigeration had not been stored in a suitable way or at the appropriate temperatures on the day of the inspection.

A few weeks ago, 30% of the items stored in the refrigerators has been removed.
The SOP’s require the fridge temperatures to be checked daily and this was discussed at the monthly meeting.
(see 3.1)