| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not always adequately identify and manage the risks associated with its services. Team members do not follow all the standard operating procedures. This increases the risks in their ways of working. |
All team members to work through all Standard Operating Procedures relevant to their role. Relevant record of competences to be signed to confirm their understanding.
Controlled Drug balance checks to be carried out weekly in line with the CD Standard Operating Procedures. |
22/04/2022 | 06/05/2022 |
| 1.2 | The pharmacy does not monitor and review the safety and quality of its services. The pharmacy does not have arrangements in place to learn when things go wrong. It does not review dispensing errors and near miss errors so the team are missing learning opportunities. |
Staff to be trained on SaferCare process and on the near miss process. All near misses to be recorded in full and in a timely manner. SaferCare to be completed weekly as per company process. Near misses and patient safety incidents to be reviewed as part of monthly SaferCare process and reviewed with the whole team as a SaferCare briefing to ensure learning opportunities are shared. |
22/04/2022 | 19/05/2022 |
| 2.1 | The pharmacy does not have enough suitably trained and skilled team members to deliver all its services safely and effectively. |
Staffing levels and staff scheduling to be reviewed (as part of right people, right place, right time – RPRPRT) to ensure that the appropriate colleagues are in at the right place at the right time to manage the workload effectively. Training matrix completed for all colleagues for dispensary tasks and provision of relevant services with sign off for each task when competent. All new colleagues to be enrolled onto the Healthcare Partner course (HCP). All colleagues to be given protected learning time for completion of their HCP within 6 months of date of enrolment. All colleagues to be given protected learning time to support with ongoing training. |
22/04/2022 | 19/05/2022 |
| 2.2 | The pharmacy does not support its inexperienced team members enough with training. So they do not have all the skills, competence, or qualifications for their roles and the tasks they carry out. |
LloydsPharmacy Pharmacist double cover support one day per week to support with the training of pharmacy colleagues. Swap of inexperienced colleagues with experienced colleague in another LloydsPharmacy store to support with training. All new colleagues to be enrolled on company induction process. Training rota to be created for all colleagues |
22/04/2022 | 19/05/2022 |
| 4.3 | The pharmacy does not store and manage all its medicines safely. It stores some medicines untidily which increases the chances of mistakes being made. The pharmacy does not have a robust date checking process and it has out-of-date medicines on its shelves. And team members do not always monitor fridge temperatures. |
Pharmacy medicines storage drawers and shelving to be re-organised alphabetically with new identifying labels to be applied to each drawer. Any loose strips of tablets to be segregated and disposed of in an appropriate manner. Medicines to be separated by strength and form. Caution stickers to be applied where appropriate to reduce risk. Dispensary fridge stock to be written off and disposed of in an appropriate manner due to temperature monitoring not being complete. Dispensary fridge stock to be re-ordered and then organised ensuring all high-risk insulin items are clearly separated and all packaging is facing one uniform direction. Staff members to be trained on fridge temperature monitoring and this must be recorded on all days the pharmacy is open. The entire Pharmacy stock, including the stock room area, to be date checked. All short-dated stock will be highlighted, and out-of-date/obsolete medication disposed of in an appropriate manner. Date checking matrix to be completed accordingly and then to be maintained following company process, with the Pharmacy Manager verifying its completion each Quarter. |
22/04/2022 | 06/05/2022 |
| 4.1 | Some people experience barriers to accessing pharmacy services which may prejudice their care. The pharmacy is sometimes closed unexpectedly during normal trading hours, so people cannot access its services. And when the pharmacy is open, people sometimes experience a delay in receiving their medicines. |
Review of Right People, Right Place, Right Time (RPRPRT) to include review of opening hours staffing levels to ensure suitably trained colleagues are present to fulfil core opening hours and therefore allow patients to access pharmacy services. Appoint a Medicines: Care and Review (MCR) champion to support with coaching of team members on MCR. Implementation of robust process for MCR to ensure patient’s prescriptions are monitored for compliance. |
22/04/2022 | 19/05/2022 |
Pharmacy inspections
Inspection reports and learning from inspections