Online Pharmacy 4U (9012620) - Improvement action plan

The pharmacy is not able to demonstrate that it carries out sufficient checks to make sure the medicines it supplies are clinically appropriate for the people requesting them. For example, there is no evidence of independent verification of people’s body mass index (BMI) for the weight management service. And safeguards to mitigate the risks when supplying pharmacy medicines liable to misuse are not consistently used.

1. BMI & Clinical Data Verification • Implementation of mandatory BMI verification process: o Photo evidence (scale + height) o Video consultation is required • No prescribing unless verified BMI recorded 2. Strengthened Prescribing Safeguards • Introduction of structured clinical assessment templates for all services • Prescriber must document: o Clinical justification 3. Medicines Liable to Misuse Controls • Quantity limits per order • ID verification + address matching enforced o Escalation process when patient keep ordering the same item o Mark the patient as high risk and when ordering again to escalate the order to the pharmacist to make a decision 4. Audit & Monitoring • Monthly audit of: o Prescribing decisions o High-risk medicines • Immediate escalation of unsafe cases

There is evidence that team members do not consistently follow the written procedures, policies and risk assessments which raises concerns about the robustness of the pharmacy’s clinical governance arrangements.

1. Full SOP review and update programme across all services (including weight loss, prescribing, and OTC supply) 2. All staff involved in OTC sales will undergo individual one-to-one training sessions led by the Responsible Pharmacist or Superintendent Training will focus on: Safe supply of OTC medicines Identification of medicines liable to misuse (e.g. codeine-containing products) Use of WWHAM questioning and escalation criteria When to refuse supply and refer to pharmacist Each session will include a competency assessment using real-case scenarios A training record and competency sign-off form will be completed and stored for each staff member Any staff identified as needing further support will receive additional targeted retraining 3. Introduction of clinical governance meetings (monthly) led by Superintendent 4. Staff required to complete annual refresher training + updates when SOPs change