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Pharmacy inspections

Inspection reports and learning from inspections

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Inspire Pharmacy (9011381) - Improvement action plan

Standard not met Reason Action being taken by the Pharmacy By when Notification By Pharmacy Improvements Made

The pharmacy does not have adequate systems in place to identify and manage risks such as suitable standard operating procedures, risk assessments prior to initiating new services and procedures in place to learn from dispensing incidents.

Fully implement Reportsmart module of the Pharmsmart suite of programmes to report near misses, incidents, prescription interventions, safety conversations and action safety alerts. These will then be reviewed each month, to produce a monthly report which will be shared with the team on a monthly basis, to learn from all of the above.

Carry out a risk assessment for high-risk OTC medicines which are sold online.

All SOPs require reviewing, updating and tailoring to suit a Distance selling environment. As a priority, we will complete this for all SOPs associated with:
• Controlled Drugs
• High risk OTC online sales
• Responsible Pharmacist regulations
• Incident reporting, Near misses and patient safety
• Stock handling
• Cold chain medicines

01/07/2021 18/06/2021

The pharmacy's responsible pharmacist (RP) record and CD registers are not accurate.

Review and update SOPs relating to Responsible Pharmacist (RP) regulations and Controlled Drugs.

Ensure all staff have read and signed the SOPs relating to RP and CDs

Complete the Responsible Pharmacist toolkit on the Royal Pharmaceutical Society website

Place notices in the Pharmacist area to remind staff to complete the RP log for their shift

Carry out a CD balance Check

Destroy any patient returned Controlled Drugs

Request for the CD accountable officer to visit in order to witness the destruction of out-of-date CDs

Going forward, to carry out a CD balance check fortnightly and to be documented on CDsmart

17/06/2021 18/06/2021

The pharmacy does not manage and store medicines in a secure and organised manner. It does not properly restrict unauthorised access to some medicines. The pharmacy cannot provide assurance that the temperature of all the medical fridges are appropriately monitored. Some medicines in the pharmacy are not stored in their original packaging and have not been appropriately labelled.

Signs placed on the pharmacy doors, to remind staff to keep doors locked to prevent unauthorised access.
Management team to continually remind staff to keep external doors locked.

Fit a push bar door lock to the fire door, so it locks automatically when closed

Fit a lock on the shutter door which locks automatically when the shutter is pulled down

Keypad door lock on the dispatch room door so there is a second locked door to get through before entry to the dispensary

CD key to be kept on the Pharmacist’s person or in the designated locked safe, with only authorised staff having access to this

Add the second fridge to the Pharmsmart monitoring system, so it prompts each day to record the temperature for the second fridge, as well as the first fridge

All stock totes to be checked and any loose tablets or strips that have been cut to be removed and duped.

Manager’s monthly audit to be devised, to check each month that the systems put in place are embedded into practice

Feedback and action points from inspection to be shared with the team in the next staff meeting, so all staff are aware of what actions need to be taken, and practice changed going forward

17/06/2021 18/06/2021

The pharmacy team carries out activities requiring pharmacist supervision without a responsible pharmacist. The pharmacy is not able to demonstrate that the medicines it sells via the internet are clinically appropriate.

Apply to NHS market entry team to change Core and Supplementary hours to fit in with the nature of the business – large number of care homes requiring a large amount of liaising with GP surgeries on most days, which on Tuesdays and Thursdays is difficult to achieve with current opening hours.

Review and update SOPs relating to Responsible Pharmacist (RP)

Ensure all staff have read and signed the SOPs relating to RP

Posters, devised by Royal Pharmaceutical Society, to be available and displayed for any occasions where the RP is not on site, detailing activities that are not to be carried out without an RP on site, and also contact details for the RP

Carry out a risk assessment for high-risk OTC medicines which are sold online.

Document all patient safety conversations, surrounding high-risk OTC sales online, on Pharmsmart, evidencing the conversations held with customers

Devise information/advice leaflets for high-risk items which are sold online, with details of ways to get support if they feel they are becoming addicted to medication

The decision to not sell Codeine linctus online had already been made prior to the inspection. Following the inspection, the decision to remove Promethazine solution and codeine based medicines from sale was also taken.

17/06/2021 22/06/2021