| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | There is not enough assurance that the pharmacy has a robust process to manage and learn from dispensing incidents and it has not ensured that these processes are sustained. Staff are still not routinely recording near misses, there are high levels of dispensing incidents occurring, full details are still not being documented and there is limited evidence of remedial activity or learning occurring in response |
All near miss incidents will be recorded, with sufficient information to assist the learning process. A monthly branch meeting will be held to review trends and patterns as a team and to avoid reoccurrences, and action taken recorded in the branch meeting book. |
16/08/2019 | 06/08/2019 |
| 1.1 | The pharmacy is not identifying and managing several risks associated with the provision of its services as failed under the relevant principles. Some of the pharmacy's standard operating procedures (SOPs) are missing or are outdated, they do not reflect current practice and staff are not always working in line with them. There are issues with Controlled Drugs and there is limited evidence that an appropriate investigation has been undertaken. The pharmacy must ensure that any remedial activity subsequently implemented is robust enough to ensure improvements will be maintained |
The branch has the current version of the SOP’s, which were sent out in in 2018. The branch has a full set of SOP’s One member of the staff of the staff did not follow the SOP’s. |
16/08/2019 | 06/08/2019 |
| 1.6 | The pharmacy is not maintaining all of its records in accordance with the law and must ensure ongoing compliance with legal requirements occurs. This includes the management and record keeping for Controlled Drugs. |
The methadone register will be checked weekly and any errors investigated with a full audit trail and notes of all evidence collected The CD register has all headers |
16/08/2019 | 06/08/2019 |
| 2.1 | The current staffing arrangements are insufficient to cope with the workload. The pharmacy does not have enough staff to provide pharmacy services safely and effectively as routine tasks were not being completed at the point of inspection. The pharmacy must ensure that a suitable number of staff are in place to routinely manage the workload and that compliance with this standard is maintained |
A new ACT to the branch will now check all of the weekly trays. |
16/08/2019 | 06/08/2019 |
| 2.4 | There is no evidence of training resources or ongoing learning provided to the team to improve their knowledge. The pharmacy needs to ensure that any activity to remediate the situation is sustained |
All of the staff will complete one virtual outcome training module a month and retain a certificate at the branch for future inspections |
16/08/2019 | 16/08/2019 |
| 4.3 | There is insufficient assurance that stock is stored and managed appropriately. There are mixed batches of medicines and loose blister strips present. There is also a lack of verifiable processes to routinely identify and remove date-expired medicines. The pharmacy should ensure that any action taken to redress this is robust enough to be maintained |
The dispensary will be date checked quarterly with a record kept of the date of checking. |
16/08/2019 | 16/08/2019 |
| 4.2 | Staff are assembling some multi-compartment compliance packs without prescriptions and supplying some medicines inside packs that are not suitable to be packaged in this way without making any of the necessary checks. Patient Information Leaflets are not routinely supplied to people with their medicines and date-expired prescriptions are present in the retrieval system. Controlled Drugs have been supplied as instalments against prescriptions that are not permitted for this purpose, in accordance with the law, the prescriptions do not contain directions to enable instalments to be made, the amount which should be supplied or the interval that should occur between dispensing. People prescribed higher-risk medicines are still not being routinely identified, counselled, relevant parameters checked, or details documented |
No prescription medication will be supplied in weekly trays without a script |
16/08/2019 | 06/08/2019 |
| 5.3 | The privacy and dignity of people who use the supervised consumption service is compromised by the position of the automated software system, used for recording and dispensing their medication |
A privacy booth has been ordered to ensure patients will not see the pharmacist preparing any methadone |
16/08/2019 | 05/09/2019 |
Pharmacy inspections
Inspection reports and learning from inspections