| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not have adequate standard operating procedures for the services it provides. |
The SOP file was found the morning after the inspection They had been signed by assistant RB in June 2018. The SOPs were due to be reviewed 02/2019. Review started in March 2019 and will be completed by September 2019. This will give sufficient time to implement FMD requirements into the SOPS. Support from the NPA for this. current SOPs used in the interim. |
05/09/2019 | 06/09/2019 |
| 1.7 | The pharmacy does not adequately separate and destroy confidential waste. |
The pharmacy team are well aware of the importance of confidential waste being disposed of in the correct manner. SI will conduct another training session to reiterate this. SI has decided against stockpiling confidential waste for incineration at the end of the month as she believe this is where the risk lies. SI has purchased a high grade shredder and asked the pharmacy team to shred all confidential waste as soon as possible or at the latest by the end of each day. Instead of having baskets to put confidential waste, which have the risk of spilling over, SI will be purchasing two red closed lid bins labelled as confidential waste. A black marker will be used to cross out any identifiable data from patient returns boxes. |
05/09/2019 | 06/09/2019 |
| 1.6 | The pharmacy's records are not legally compliant. Records including the RP log and private prescriptions records are incomplete, and records of unlicensed medicines obtained as 'specials' were not available. |
Responsible Pharmacist records are now being more stringently monitored. Each Pharmacist is being told to make sure they are logged in as soon as they assume responsibility and also to ensure they are signing out when they cease responsibility. Private prescriptions are routinely entered to meet legal requirements as can be seen by all previous entries. However, two prescriptions were found not to be entered on the day of the inspection. SI will be writing to the locum pharmacist on duty to make them aware of their obligations as the Responsible Pharmacist. The two dispensers have been informally spoken to about legal requirements and record keeping requirements for private prescriptions. SI will also ask both dispensers to go over their dispensing modules which covers private prescriptions and record keeping during a dedicated training session. SI to audit the private prescription book on a monthly basis just to make sure everything meets the legal requirements. Pharmacy in the process of speaking with a pharmaceutical IT company with the intention of computerising all legal records, including CD register, POM register, fridge temperature records. SI hoping to achieve this in the next 2 months. All records for unlicensed medicines obtained as specials are available. During the clear up, the weekend before the inspection, some of the records were taken up to the store room. SI will make all of them available . |
05/09/2019 | 06/09/2019 |
| 2.2 | One member of the pharmacy team is not qualified or appropriately trained for the activities they carry out. |
assistant RB has been enrolled onto the Buttercup Healthcare assistant course which encompasses both the over the counter training and dispenser training. She will only assume duties that she has received sufficient training for. Her roles and responsibilities will be discussed with her and set out for her. |
05/09/2019 | 06/09/2019 |
| 4.2 | The pharmacy assembles and checks multi-compartment devices without reliable audit trails and stores them unlabelled and unsealed for extended periods. |
Dispensers will be asked to complete one Dossette box from start to finish I.e. labelled and dispensed ready for checking by the pharmacist. Rather than dispensing several and then labelling them. Dispensers will be asked to initial the Dossette sheets as they are doing on dispensing labels. |
05/09/2019 | 06/09/2019 |
| 4.3 | Stock medicines are poorly organised and the pharmacy cannot provide assurance that the temperature of one of the medical fridges is appropriately monitored. |
The medicine shelves have now been better organised, some shelves are still in the process of being cleaned and rearranged. This will be completed by 16/08/2019. A new fridge temperature log book has been purchased and in operation. Dispensers have been asked to record both fridge temperatures. A new fridge with a greater capacity is being delivered on the 13/08/2019. This will allow the fridges to be better organised. Team are also hoping to make the fridge temperature records electronic in the next few months. |
05/09/2019 | 06/09/2019 |
Pharmacy inspections
Inspection reports and learning from inspections