Roade Pharmacy (9012696) - Improvement action plan

The pharmacy does not effectively manage key risks associated with some of the services it provides. It does not effectively manage its medicines that require safe storage. And it does not manage all the risks with its private weight management service. The pharmacy was operating under an expired weight loss Patient Group Direction (PGD) and has inadequate systems in place to ensure it always has all the appropriate current authorities in place to supply prescription only medicines. And it does not keep suitable records of its consultations and share information with the patient’s regular prescriber when consent has been given.

The pharmacy has now moved all of its expired CDs that were previously recorded in paper registers into the electronic registers so that all entries are recorded in one system, reducing the risk of omissions or confusion. The pharmacist is now using their correct and updated log-in details for the Numaad PGD service, which was already purchased prior to the inspection but could not be accessed at the time due to incorrect log-in details. All private services provided at the premises are now supported by up-to-date PGDs signed by the pharmacist, and only these PGDs are used for the supply of prescription-only medicines. The pharmacy will implement a monthly check of all PGDs in use to make sure that they remain in date and are appropriate for the services being provided. A record of these checks will be kept. Numaad includes an integrated email notification which triggers an email being sent to the patient’s GP when consent has been given following a private consultation with our pharmacist. By utilising the Numaad PGD platform, the pharmacist, follows a structured consultation process which prompts the pharmacist to ask appropriate clinical questions which in turn, highlight any potential risks associated with weight loss medication.

The pharmacist supplies weight loss medicines against a private PGD. But the pharmacist does not keep appropriate records of the consultation they have carried out. This makes it more difficult to explain their decision to supply a medicine if something goes wrong and does not allow another pharmacist to understand their rationale for prescribing if they are carrying out the next consultation.

With correct log-in details now in place, the pharmacist is no longer using paper copies of outdated PGDs to record private consultations. The pharmacist is fully utilising the Numaad platform which provides a structured approach to consultations and ensures clinical assessments, decision-making rationale, outcomes and follow-ups are clearly documented. This allows other pharmacists to understand previous consultations and supply decisions, supporting continuity of care and patient safety.