| 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 risks associated with the services it provides. Team members are not aware of any formal procedures relating to the pharmacy's hub and spoke model. And the clinical check of prescriptions dispensed by the hub pharmacy are not recorded. |
All staff will read standard operating procedures (SOPs) relating to data entry for Hub compliance aid production. Responsible Pharmacist (RP) will perform ‘clinical check’ via patient medication record (PMR) on prescriptions to be sent to Hub. |
11/10/2021 | 03/11/2021 |
| 1.2 | The pharmacy does not encourage its team members to record mistakes made during the dispensing process. And it has no suitable process in place to monitor and act upon the mistakes made to improve patient safety. |
RP will log near misses/errors and communicate back to team in a learning process. ‘LASA’ meds will be acted upon and feedback from RP will be regularly communicated. |
11/10/2021 | 22/10/2021 |
| 1.6 | The pharmacy does not make and maintain all of its records in accordance with legal and regulatory requirements. |
Controlled Drug (CD) register will be entered on receipt and regular balance checks undertaken. All relevant pharmacy records will be made contemporaneously. RP logs, private prescription logs will be maintained in line with requirements using paper books. Folder for certificate of conformity will be implemented for appropriate record keeping. All SOPs to be read, signed and dated in accordance to job title. |
11/10/2021 | 03/11/2021 |
| 2.2 | Not all pharmacy team members in training roles are undertaking the training required for their role. And team members enrolled on training courses are not receiving regular support to help ensure their training progresses smoothly. |
Staff will be enrolled or in the process of enrollment for the job they are required to perform. Those who are on training courses will be given a ‘mentor’ who will be able to support regularly. Protected training time will also be arranged. |
11/10/2021 | 03/11/2021 |
| 2.5 | There is evidence of insufficient action being taken when team members raise legitimate concerns. |
Staff will be advised of senior staff they can report concerns to, and how they will be dealt with. |
11/10/2021 | 03/11/2021 |
| 4.3 | The pharmacy does not store medicines requiring refrigeration in appropriate conditions. And it does not have adequate arrangements in place to support the management of medical waste. |
Medicine wastage collections will be arranged and set up on a regular basis. Storage of waste medicines will be set away from public access and in a designated area. Cold chain medicines will be more suitably stored in fridges, with no food or beverages to be placed in designated areas. |
11/10/2021 | 22/10/2021 |
Pharmacy inspections
Inspection reports and learning from inspections