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Paragraph 26 Clinical governance

Changes not yet applied. Later legislation changes this provision in ways not yet written into the text below:

(1)

A pharmacist shall, in connection with all the pharmaceutical services provided by him, participate, in the manner reasonably required by his Primary Care Trust, in an acceptable system of clinical governance.

(2)

For these purposes a system of clinical governance is “acceptable” if it is considered acceptable by the Secretary of State and comprises the following components—

(a)

a patient and public involvement programme, which includes—

(i)

a requirement that the pharmacist should produce in an approved manner, and make available in an appropriate manner, a practice leaflet in respect of his pharmacy,

(ii)

a requirement that the pharmacist publicises the NHS services that are available at or from his pharmacy,

(iii)

a requirement that the pharmacist should undertake an approved patient satisfaction survey annually, in an approved manner,

(iv)

the pharmacist’s monitoring arrangements for drugs or appliances owed to patients but which are out of stock,

(v)

an approved complaints system (which meets the requirements of this Part),

(vi)

a requirement that the pharmacist co-operates appropriately with local Patients' Forum visits and takes appropriate action following the outcome of such visits,

(vii)

a requirement that the pharmacist co-operates appropriately with any reasonable inspection or review that the Primary Care Trust or any relevant statutory authority wishes to undertake, and

(viii)

the pharmacist’s monitoring arrangements in respect of his compliance with the Disability Discrimination Act 1995;

(b)

a clinical audit programme (normally of five days), which includes at least one pharmacy-based audit and one multi-disciplinary audit agreed by his Primary Care Trust in each financial year;

(c)

a risk management programme, which includes—

(i)

arrangements for ensuring that all stock is procured and handled in an appropriate way,

(ii)

arrangements for ensuring that all equipment used in the provision of pharmaceutical services is maintained appropriately,

(iii)

an approved incident reporting system, together with arrangements for analysing and responding to critical incidents,

(iv)

appropriate standard operating procedures, including standard operating procedures in respect of dispensing drugs and appliances, repeatable prescriptions and providing advice and support to people caring for themselves or their families,

(v)

appropriate waste disposal arrangements (in addition to those required under Part 2) for clinical and confidential waste,

(vi)

a clinical governance lead person in respect of each pharmacy,

(vii)

appropriate child protection procedures, and

(viii)

the pharmacist’s monitoring arrangements in respect of his compliance with the Health and Safety at Work etc. Act 1974;

(d)

a clinical effectiveness programme, which includes arrangements for ensuring that appropriate advice is given by a pharmacist in respect of repeatable prescriptions or to people caring for themselves or their families;

(e)

a staffing and staff management programme, which includes—

(i)

arrangement for appropriate induction for staff and locums,

(ii)

appropriate training for all staff in respect of any role they are asked to perform,

(iii)

arrangements for the checking of qualifications and references of all staff engaged in the provision of NHS services,

(iv)

arrangements for identifying and supporting the development needs of all staff engaged in the provision of services as part of the health service, including continuing professional development for registered pharmacists and any necessary accreditation in respect of the provision of directed services, and

(v)

arrangements for addressing poor performance (in conjunction with a Primary Care Trust as appropriate); and

(f)

a use of information programme, which includes—

(i)

appropriate arrangements (having regard to issues both of rights of access to information and of confidentiality) to support both health care delivery and clinical governance,

(ii)

appropriate arrangements in respect of compliance with “Confidentiality: the National Health Service Code of Practice”f1,

(iii)

the pharmacist’s monitoring arrangements in respect of his compliance with the Data Protection Act 1998 and with regard to patient confidentiality, and

(iv)

appropriate training for staff with regard to compliance with the Data Protection Act 1998 and patient confidentiality,

and for the purposes of this sub-paragraph, “approved” means approved by the Secretary of State.

Annotations

Footnotes

f1

This Code of Practice is available at www.dh.gov.uk/publicationsandstatistics.