Xeal Dispensary (9011996) - Improvement action plan

The pharmacy cannot demonstrate that it adequately considers and manages the risks associated with its services, in particular with respect to the invidual medicines it supplies at a distance. The pharmacy has written instructions to help deliver its services. However, not all team members have read these so they may not know the right procedure to follow. The pharmacy does not always follow its own complaint's procedure. Team members do not have adequate oversight of how the relevant clinics have dealt with complaints and the outcomes of any investigations. This means that there is a risk that opportunities to learn and make the pharmacy’s services safer are missed.

• Risk assessment is in progress, covering all services provided by the Pharmacy including emphasis on CBPM dispensing
• All staff to read and sign SOPs
• Review and update complaints SOP, specifying how different types of complaints are to be handled
• All complaints received by clinics to be reported to the Pharmacy for review and outcome to be discussed with the Pharmacy

The pharmacy provides specialised services, but it is unable to provide sufficient assurances that its team members have received relevant training about these services. And the pharmacy does not sufficiently support its team members with ongoing learning to help keep their skills and knowledge up to date.

• All pharmacy support staff to be enrolled onto Buttercups ‘Pharmacy Support Worker’ course.
• Internal training programme covering CBPMs will be developed for all staff dedicated to the unique services that Xeal Dispensary provide
• Staff appraisals to be carried out every 6 months
• Pharmacists to undergo CPPE/e-LFH Training module ‘Cannabis Based Products for Medicinal Use’