| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.1 | The pharmacy does not identify and manage all of the risks involved with its services. For example, it supplies some medicines for conditions which require ongoing monitoring and cannot demonstrate that it shares relevant information about the person's treatment with their regular GP. The pharmacy’s risk assessments for the online prescribing service are brief, general and missing details. The pharmacy does not always follow through with the actions identified in its own risk assessments. |
Risk assessment to be updated to include all the medications we are supplying so a more detailed consideration of the risks involved are made for a better managed and safer service to patients. Appropriate NICE guidelines will be referenced in the risk assessment. SOPs and risk assessment regarding the supply of Orlistat will be updated to make sure we refer the patient to their GP or to a weight loss clinic when necessary. All registers/record logs will be updated and maintained daily and readily available to demonstrate that all the necessary records are maintained. Near miss logs will have regular monthly audits in place at the end of each month and the outcomes of the audits will be documented. Risk log will contain patients and prescriber’s details, include contributory factors to the risk and learning points to ensure the risk will be eliminated/mitigated in future. For the medications that need ongoing monitoring such as inhalers a register will be maintained to record each time a patient’s GP is informed of a supply. All the procedures contained in the risk assessment will be followed through and documented in record logs. |
24/09/2021 | 24/09/2021 |
| 1.2 | The pharmacy does not carry out audits or reviews of its prescribing service. So, there may be associated risks that are not being properly identified and managed. And it makes it harder for the pharmacy to demonstrate that its services are safe and effective. |
A yearly audit of our prescribing services will be performed. The date of the next audit will be 1/10/2021 and will be completed by 15/10/2021. The audit will be performed by the superintendent pharmacist, independent prescriber(s) and the head of operations. The audit will review all the prescription medications we supply. All the questionnaires will be reviewed as well as the current guidance for prescribing. All the decisions and changes made during the audit will be documented in a designated audit folder that will be readily available to demonstrate if necessary. Current SOPs will be updated to include a procedure for absence of the RP (Business continuity plan). SOPs will be read and signed by all team members. Both computers present in the office will be password protected and keys to the premises will be only held by the authorised personnel (SI, dispensing assistant, and head of operations). |
24/09/2021 | 29/11/2021 |
| 1.6 | The pharmacy does not routinely make records of any communication it has with people’s GPs. So, it cannot demonstrate what was communicated, and cannot audit this activity. The pharmacy does not maintain a record of the reason for its prescribing decisions. And it does not maintain a full record of private prescriptions it dispenses. |
Records will be maintained to demonstrate all the communication performed with patients’ GPs. The prescriber will be maintaining his/her own log of decisions made to prescribe or not to prescribe a medication. Full record of private prescriptions dispensed will be maintained electronically. Regular training for the staff will be provided through CPPE and other resources. Data protection and safeguarding learning will be taken by all staff including assistants and SI, certificates of completion will be available at the pharmacy.
Robust contingency plan will be put in place and included in the SOPs to ensure that continuity of the services is in place in case of an emergency. Training records (such as CPPE certificates) will be kept for all the staff. Targets will be set for the team by head of operations. |
24/09/2021 | 24/09/2021 |
| 3.1 | The pharmacy's website allows people to select prescription-only medicines before they have a consultation with a prescriber. |
The patient journey on the pharmacy’s website will be updated so that a consultation is completed with a prescriber before any prescription only medicine is offered to the patient. |
19/11/2021 | 19/11/2021 |
| 4.2 | The pharmacy cannot always demonstrate that it shares any relevant information about consultations or prescriptions with other healthcare professionals involved in people's care, including their GP. And it does not always follow the relevant guidance. |
Records will be maintained to demonstrate all communication and information shared with patients’ GPs and healthcare professionals. |
24/09/2021 | 24/09/2021 |
| 4.3 | The pharmacy does not always store its medicines securely. And it does not routinely date check its stock medicines. It doesn’t keep all its medicines in appropriately labelled containers. So, there is a risk that people receive medicines that are past their expiry date. The pharmacy cannot sufficiently demonstrate that it disposes of its waste medicines safely. |
Expiry date check of all the medication will be performed every two months. The batch number and expiry dates are also checked and documented by the RP at the time of dispensing on a printed prescription. The dispensary will be reorganised in a way that all the medication is stored securely, there is no risk of tripping for the staff, medicines with similar names are clearly separated and dispensary is labelled to increase the safety of the dispensing process. Different strengths of the same medication will be clearly separated, there will be no lose blisters and it will be always possible to identify the batch number and expiry date of any opened medication. The disposal of returned/expired medicines will be taken care of safely by a licenced medical waste disposal company. Phone line accessibility will be adjusted in a way that all the calls between 9-6 will be either answered by the staff in the office or re-directed to the RP when there is no one available to take the call in the pharmacy. Safety alerts log will be put into place and every action taken after receiving a safety alert will be properly documented. Missing Royal Mail deliveries log will be maintained and updated each and every time an order is not delivered / returned. SOPs for the supply of the inhalers will be updated. SOPs and risk assessment for prescribing chlamydia treatment will be updated - first line treatment being doxycycline. For pregnant women we will suggest Azithromycin as an alternative. Everyone that will get prescribed chlamydia treatment will receive a leaflet informing them about additional screening needed and providing extra counselling. |
24/09/2021 | 24/09/2021 |
Pharmacy inspections
Inspection reports and learning from inspections