| Standard not met | Reason | Action being taken by the Pharmacy | By when | Notification By Pharmacy Improvements Made |
|---|---|---|---|---|
| 1.2 | The pharmacy does not have a robust process in place to manage and learn from incidents. There is no evidence that the team has been routinely recording details about incidents, complaints or near misses, and no evidence of remedial activity or learning occurring in response to mistakes. |
A new near miss log is being kept up to date in the dispensary. To make sure this is being utilised each page which has 9 possible entries will be reviewed when its completed or at the |
18/08/2023 | 05/10/2023 |
| 1.1 | The pharmacy is not identifying and managing several risks associated with its services as indicated under the relevant failed standards and Principles below. The staff are not routinely working in line with all of the pharmacy's standard operating procedures (SOPs). |
SOPs are to be reviewed by the staff. Regular formal team meetings will be arranged to check standards are being kept by identifying risks e.g. near misses and review how and why these take place and how to better improve to reduce the reoccurrence of these events |
18/08/2023 | 05/10/2023 |
| 1.6 | All necessary records to verify that pharmacy services are provided safely should be readily available for inspection. The pharmacy has been unable to demonstrate that it has been keeping all the records it needs to prove this. At the point of inspection, the pharmacy was unable to locate any records to verify that it had been recording supplies of unlicensed medicines as required by law. And private prescriptions which had been dispensed and supplied by the pharmacy were stored elsewhere. |
Space has been created to store the filing legally required on site so it to hand should an inspector wish to see it in future. This was done by refitting the staff room into the stock room with a section dedicated to files containing the information legally required to be kept on site. |
18/08/2023 | 05/10/2023 |
| 1.8 | The pharmacy's team members cannot effectively demonstrate that they know how to safeguard the welfare of vulnerable people. The pharmacy's SOP to provide guidance on this is insufficient and there are no details of local agencies available to suitably signpost or raise concerns if needed. This puts vulnerable people at risk. |
New SOPs have been added to complete the safeguarding section. Staff have reviewed this and have also been asked to recomplete the ELFH safeguarding training as their knowledge on identifying safeguarding concerns in practice was lacking. Additionally details of where to signpost patients or raise concerns regarding safeguarding have been printed and put up in an accessible place for the team. |
18/08/2023 | 05/10/2023 |
| 4.4 | The pharmacy cannot fully verify that it has the appropriate procedures in place to raise concerns when medicines or medical devices are not fit for purpose. The pharmacy only has old records available from January 2023 or 2022. Specific emails about the drug alerts issued by the Medicines and Healthcare products Regulatory Agency could not be accessed. And team members do not know how to or cannot fully demonstrate that they have actioned the drug alerts appropriately. |
The team have a whatsapp group chat with all members present. MHRA notifications will be shared using this and receipt of this will be confirmed in writing via message on the group chat. Following this, the MHRA notification will be printed and filed in a folder marked drug alerts. The notification will be actioned by the RP and a note of the date it has been shared and actioned will be noted on the document in the file. |
18/08/2023 | 05/10/2023 |
| 4.3 | The pharmacy is not managing its medicines in a satisfactory way. This compromises the safe supply of medicines and medical devices. Medicines are often stored haphazardly on the floor or in inappropriate places. Team members cannot show that they have consistently been checking medicines for expiry. Short-dated medicines are not identified in a clear enough way or in line with the pharmacy's operating procedures. And the staff cannot show that they have been storing medicines requiring refrigeration at the appropriate temperatures. |
A fridge log has been kept daily as the job has been assigned to a member of the team as part of their morning routine to make sure this gets done every day. The previous staff room has been rebuilt into a stock room to maintain the increased stock levels required to service the patient group. The main dispensary has also been changed to increase storage space capacity as it was noted that stock was being kept inappropriately. A stock |
18/08/2023 | 05/10/2023 |
| 4.2 | The pharmacy does not have appropriate procedures in place to identify and manage people prescribed higher-risk medicines. |
We have warning labels to be added when bagging prescriptions so that the staff handing out the medicine are aware that their is high risk medication as well steroid cards and anticoagulant cards on site. |
18/08/2023 | 05/10/2023 |
Pharmacy inspections
Inspection reports and learning from inspections