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Pharmacy inspections

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Fusion Pharmacy (9010891) - Improvement action plan

GPhC Reference 9010891

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 for reviewing near misses and dispensing errors. Its date checking processes are inadequate.

The ‘Near Miss’ register has been relocated to a prominent position next to the pharmacist, and all near misses are to be recorded immediately upon occurrence.
RxSystems have been contacted to learn how to review dispensing errors which have been input into the PMR system, these will be reviewed monthly.
Date check matrix has been implemented and will be carried out on a rolling weekly basis to ensure each section is covered once per month.

 30/06/2021 01/07/2021
1.2

The pharmacy has inadequate processes for monitoring and reviewing services to ensure they are safe.

SOPs for all services are currently under
review and are due to be re-signed by all members of staff. The pharmacy has an SOP covering ‘MDS in nursing homes’. This SOP has also been reviewed to ensure it is brought in line with our care home service.

 30/06/2021 01/07/2021
1.6

The pharmacy does not maintain the records it is required to by law.

Controlled Drug register brought up to date, all entries made with no discrepancies found.
CD entries to be made immediately upon
receipt/delivery of drugs and balance check to be completed every Monday morning.

 30/06/2021 01/07/2021
2.1

The current pharmacy team struggles to manage both the dispensing workload and carrying out the clinical governance tasks required for the safe and effective running of a pharmacy.

Additional staff members are being recruited.
Apprentice agency has been contacted
multiple times in recent months but there seems to be a short supply of apprentices. Job ads to be posted on more sites to attract more interest. Interviews have been confirmed and are being carried out currently.

 30/06/2021 01/07/2021
3.1

The pharmacy does not make sure all parts of the premises are kept in a clean and tidy condition.

Cleaning rota will be strictly implemented. Along with cleaning of shelves to go alongside date checking, rota for vacuuming and clearing up rubbish will be adhered to.
Rubbish to be cleared before the end of each day.

 30/06/2021 01/07/2021
4.3

The pharmacy doesn’t routinely date check its stock medicines or record the date of opening on bottles of liquid medicines. This increases the risk that people may get medicines that are no longer as effective as they should be.

Date checking matrix to be utilised correctly, this will be done on a weekly rotation to ensure all sections of the dispensary are covered on a monthly basis. Any liquids which are split will have a date written on in marker pen and staff will be reminded that there will be a new 3 month expiry on any split liquids.

 30/06/2021 01/07/2021
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