Skegness Pharmacy (9011112) - Improvement action plan

The pharmacy does not undertake any audits of its private prescribing service. So, it cannot provide assurance that the service continues to be provided safely.

Create and develop an audit framework for the private prescribing service that includes: Areas of the service that require monitoring Audit criteria and measurable standards, including documentation quality, patient safety checks - Outline an audit frequency in a given time frame and a reporting process Using this framework, create an audit checklist/template to be used to review prescribing consultations. This should include: Completeness of consultation records Clinical appropriateness of prescriptions Evidence of clinical assessment and decision-making Compliance with SOPs Using the template and framework above, introduce routine prescribing audits into pharmacy practise. Document the findings of these audits, identify any risks or trends and outline any corrective measures. Share any learning with other pharmacy staff and file the documentation into an audit folder. Annually review the audit process and update the programme if necessary.

Some of the pharmacy's written procedures contain inaccurate information about how the pharmacy provides its services and so does not reflect the pharmacy’s current practice. And the pharmacy doesn't always ensure all team members have completed learning for the procedures relevant to their role.

Conduct a comprehensive review of all existing SOPs to ensure they accurately reflect the pharmacy’s current services and processes. Update SOPs where discrepancies are identified. Ensure all team members read and understand the SOPs relevant to their roles. Require all staff members to sign a declaration confirming they have read, understood, and will follow relevant SOPs.

The pharmacy has no risk assessments or policies in place for providing its prescribing service, so it cannot show how it identifies or manages the risks for this service.

Carry out a formal risk assessment for the pharmacy prescribing service by: Identifying the risks related to prescribing activities Evaluate the likelihood and impact of each risk Document risk mitigation strategies Create and develop a prescribing service policy that includes: Scope of prescribing services offered Patient eligibility Consultation process and clinical assessment Documentation requirements Communication with the patient’s GP where appropriate Safeguarding considerations, record retention and confidentiality Escalation and referral procedures Create and retain standard operating procedures for: Independent prescribing consultation process Decision-making and prescribing limits Incident reporting and learning

The pharmacy does not keep some of its records in accordance with requirements. Pharmacists do not routinely sign-out of the responsible pharmacist record when ceasing their role and the pharmacy does not always complete the necessary records when supplying unlicensed medicines to people.

Review the legal and regulatory record keeping requirements to ensure the pharmacy is fully aware of their obligations. Identify the gaps between current practice and regulatory requirements Develop standing operating procedures for completing pharmacy records, including: Accurate completion of RP record to ensure RP is signing in and out of their role Documentation requirements when supplying unlicensed medicines including prescriber details, patient details, product supplied and justification where required. Record storage and retention Introduce daily and weekly record-keeping checks to ensure compliance with requirements.

The pharmacy does not maintain clear consultation records for its prescribing service. The prescriber does not consistently document the information discussed during consultations, including the rationale for prescribing decisions, ongoing monitoring, or consideration for any follow-up required. This means important information may not always be available to ensure the pharmacy supplies its medicines safely.

A standard consultation template in Microsoft Word format will be introduced for all prescribing consultations. The template will be used for: • Weight-loss injection prescribing • Minor illness consultations The template will include mandatory sections to ensure complete documentation, including: • Patient identification details • Medical history • Current medication • Allergies • Presenting complaint • Clinical assessment • Treatment options discussed • Prescribing decision and clinical rationale • Safety checks and contraindications • Advice given to the patient • Monitoring requirements • Follow-up arrangements Completed consultation forms will be stored securely in the pharmacy’s clinical records folder or electronic system. Records will be maintained in line with data protection and confidentiality requirements. A letter will be sent to the GP practice via secure NHS email for the treatment provided in the Pharmacy.