| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy SOPs do not always reflect current practice. |
New and updated SOPs will be given to all staff to familiarise themselves with and signed once completed. Once new SOPs are in place staff will be asked to re-read them if a mistake re-occurs on several occasions. |
14/11/2023 | 22/11/2023 |
| 1.6 | The pharmacy does not keep appropriate controlled drug (CD) records and the responsible pharmacist (RP) record is incomplete. |
The electronic RP record will be reviewed for gaps and filled in as much as possible. The pharmacy manager will be responsible for reminding locums to use the RP record. Note - The Notice of intention to impose Conditions served on 20 October 2023 relates to lack of appropriate controlled drug (CD) records. |
14/11/2023 | 22/11/2023 |
| 1.2 | The pharmacy cannot provide any evidence to show how it learns from things that go wrong. |
A paper near miss log will be used by all staff, replacing the electronic one which was inaccessible. Periodic near miss review meetings will also take place. |
14/11/2023 | 22/11/2023 |
| 2.1 | The pharmacy is operating without a superintendent pharmacist. |
Actively seek a new superintendent pharmacist and liaise with pharmacy contacts to find a pharmacist to appoint promptly. |
14/11/2023 | 22/11/2023 |
| 4.3 | Some stock medicines have been re-packaged and are not adequately labelled. So the pharmacy cannot provide assurance that they are fit for purpose. |
Go through the stock on the shelves at the side of the robot and doop any inadequately labelled stock. Highlight to staff how split medication / medication that is re-packaged should be labelled and the necessary information that needs to be included on the medicine label. |
14/11/2023 | 22/11/2023 |
Pharmacy inspections
Inspection reports and learning from inspections