| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy fails to identify and manage the risks associated with providing its services. It does not have adequate procedures in place for the supply of compliance packs. And it does not have adequate procedures and training for staff to protect vulnerable patients. |
To review Sops and update as soon as possible (more specific to our pharmacy) -New updates SOP for blister pack procedure and running of internet pharmacy. -Train all staff including my delivery driver on procedures and protocol to protect vulnerable patients. |
03/09/2019 | 12/12/2019 |
| 1.2 | The pharmacy fails to adequately review and monitor the safety and quality of pharmacy services. It doesn't have sufficient contingency plans to cope safely with the growth of the business. |
Record all near misses at every opportunity without fail and to discuss with the pharmacy team on a weekly basis. -Before taking on addition prescriptions we will first assess whether we have the appropriate staff levels and are able to cope with the added work levels. Ensuring patient safety is at its highest level. |
03/09/2019 | 12/12/2019 |
| 1.6 | The pharmacy fails to maintain its CD registers and the responsible pharmacist log in accordance with legal requirements and best practice. |
CD check are to be carried out every month without fail (in accordance with the SOP’s) -CD will be entered in the register on a daily basis as soon as dispensed. A new basket has been made (CD’s to Enter). All entries will be made before the end of the day without fail. |
03/09/2019 | 12/12/2019 |
| 1.8 | The pharmacy team does not have adequate procedures to ensure that children and vulnerable adults are safeguarded. |
SOP’s for safegaurding concerns will be produced immediately and to ensure all staff have signed and understood. -Train all staff again including our driver in relation to safegaurding and correct protocol procedures. |
03/09/2019 | 12/12/2019 |
| 2.2 | Staff do not have the appropriate skills and competencies for their roles. |
Re-train all staff on assembly of multi compartment compliance packs to ensure the safest and best practice. Also SOP’s will be updated, signed and understood by all staff. |
03/09/2019 | 12/12/2019 |
| 2.4 | The pharmacy does not have a culture of openness and honesty. |
Whistle blowing policy SOP to be read and signed by all staff. A culture of openness and honesty will be built up by allow staff and pharmacist all to discuss views openly and to discuss issues with the pharmacy. A new book has been created allows staff to write down any suggestion, view or if have any concerns. In addition the pharmacist will have weekly discussion with the staff to ensure an openness culture is present within the pharmacy. |
03/09/2019 | 12/12/2019 |
| 2.5 | The pharmacy team members are not encouraged to provide feedback and raise concerns about making sure that the pharmacy is running safely. |
Formal staff appraisal will be held on a regular basis. -All staff will be encouraged to give more feedback and as a team we will ensure the running of the pharmacy is at the highest level. |
03/09/2019 | 12/12/2019 |
| 4.2 | The pharmacy does not manage the way it prepares multi-compartment compliance packs safely. |
The making up of the blister trays will be reviewed to ensure patient safety is at its highest -We will ensure the tray are not made up until we have a valid prescription in place along with stock. -We will ensure dispensed box and checked box are signed at the end of the dispensing process -We will ensure patients charts are updated with dates and relevant information, as well as presenting tidy. -We will ensure the blister trays are only made up once we have all the stock, and that they are not left open. |
03/09/2019 | 12/12/2019 |
| 4.3 | The pharmacy does not ensure that all its medicines are safe and fit for purpose. |
We will ensure fridge temperatures are monitored and recorded daily. -We will ensure date checks are carried out every month without fail in accordance with SOP’s. -We will ensure date of assembly is added to non-original containers as well as batch numbers and expiry dates. -We will ensure delivery records of patients names and address are kept for audit trails. -We will ensure high risk patients are provided with appropriate information and I will follow up with phone calls. We will have leaflets at the pharmacy -We will ensure all medicine safety alert are printed, actioned and followed up. All staff will be aware of the alerts. |
03/09/2019 | 12/12/2019 |
Pharmacy inspections
Inspection reports and learning from inspections