CPAF 2010-12

8/8/2019 CPAF 2010-12

1/22

1

Community Pharmacy Assurance Framework (CPAF) for contract monitoring

Date of Visit: Full or Short Visit:

Group or Independent: PCT Assessor:

Name of Pharmacist: Pharmacist Assessor:

Address of Pharmacy: Lay Assessor:

Date Report sent to Pharmacy:

Date of Final Rating:

Final Rating:

0 =non compliant; 1 =compliant; 2 =best practice.

For ease of use, the Service Indicators in this CPAF have been abbreviated. Terms of Service (ToS) are set out in Part 1,

Schedule 1, of the NHS (Pharmaceutical Services) Regulations 2005. Core & Developmental Standards (S4BH) are mapped

from http@//www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidanceBrowsable/DH_4894544

8/8/2019 CPAF 2010-12

2/22

2

Essential Service 1 (ES1) - DispensingThe supply of medicines & appliancesordered on NHS prescriptions, together withinformation & advice, to enable safe & effectiveuse by patients & carers, & maintenance of appropriate records.

Service Indicators Visit Questions Visit AnswersVisit

Rating

Agreed Actionto reachCompliance (1)

Recommendationto reachBest Practice (2)

By

whom

By

when

PCT commentsFinal

Rating

ToS - 5(2)S4BH- C4,D1ToS - 7(1)S4BH - C13,C16,D9ToS - 7(3) & (4)S4BH - C7

Do you have DispensingSOP/s? (Mandatory):1. Prescription Handling2. Assessment of

Prescription (validity,safety etc)

3. Interventions & Problems4. Assembly & Labelling5. Accuracy Checking6. Transfer to Patient YES 1 none n/a 1

Does it have a review date? YES 1 none n/a 1Is it signed by all relevantstaff? YES 1 none n/a 1

Does it cover timeestimates

fordispensing? YES 1 none n/a 1

Does it include theneed toask for proof ofentitlement toexemptions? YES 1 none n/a 1

ToS - 26(2)(a)(iv)

S4BH - C4, C9

Do you have monitoringarrangements in place for

medicines or appliancesowed to patients, e.g. owingsreport? YES 1 none n/a 1

ToS - 10 (d) & 10(e)(iii)

ToS - 10(b)

Is an owing note providedif aprescriptioncannot be

fulfilled? YES 1 none

n/a1

8/8/2019 CPAF 2010-12

3/22

3


Rating



By

whom

By

when

PCT commentsFinal

Rating

S4BH - C4, C16, C22,D1, D2S4BH - D1

Is a recordkept of owings? YES 1 none n/a 1Do you remind people tostore their medicines safely?

y Orally

y Dispensing label

y Dispensing bag YES (ticks) 1 none n/a 1ToS - 10(a)(i) & (ii)

S4BH - C4, C16, D9

ToS - 10(e)(ii)

S4BH - C4, C16, D9

Do you give appropriateadvice whenhanding out

medicines? YES 1 none n/a 1Do you keep records of anyinterventions or referralsmade, whereclinicallyappropriate? YES 1 none n/a 1

ToS - 11(1)S4BH - C16, D9

ToS - 11(2)S4BH - C16, C18, D11

Is the pharmacy able tooperate the Electronic

Prescription Service?

y Release 1 enabled

y Release 1 not enabled

y Release2enabled

y Release2not enabled YES (tick) 1 none n/a 1Are you able to set thenomination of a dispensingcontractor at patientsrequest? YES 1 none n/a 1Have relevant staff beentrainedin EPS? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

4/22

4

Essential Service 2 (ES2) - Repeat DispensingManagement & dispensing of repeatable NHS prescriptions for medicines & appliances, in partnership with patient & prescriber.ES2covers requirements additional to those for ES1, such that the CP ascertains patients need for a repeat supply &communicates any clinically significant issues to prescriber.


Rating

Agreed Actionto reach

Compliance (1)

Recommendationto reach

Best Practice (2)

By

whom

By

when

PCT commentsFinal

Rating

ToS - 10(f)S4BH - C5, C11, D2

Do you & relevant staffhaveevidence of training? YES 1 none n/a 1

ToS - 5(3)

S4BH - C4, D1

ToS - 10(c) & 26(2)(d)

S4BH - D2

ToS - 9(2) & 9(3)

S4BH - C6, C22

Do you have an SOP?(Mandatory) YES 1 none n/a 1

Does it have a review date? YES 1 none n/a 1

Is it signed by all relevantstaff? YES 1 none n/a 1

Does SOP require CP &relevant staff to provide

appropriate advice topatients, including importanceof only requesting thoseitemswhich are actually needed? YES 1 none n/a 1Do you check that thepatient is likely to continue totake or use medicines orappliances? YES 1 none n/a 1Do you check that the patientis not suffering any side

effects from the treatment? YES 1 none n/a 1Do you check that thepatients medication regimenhas not been altered? YES 1 none n/a 1Do you check that thepatients healthhas not YES 1 none n/a 1

8/8/2019 CPAF 2010-12

5/22

5


Rating



By

whom

By

when

PCT commentsFinal

Rating

changed?

Does SOP require CP torefuse to dispense whenapplicable? YES 1 none n/a 1If yes, which of the following

refusal criteria does itspecify? n/a n/a n/a n/a n/a

CP has no record of thatprescription YES 2 none 2 2CP has no associatedbatchissue & repeatableprescriptionis notpresented

YES2 none 2 2

It is not signed by arepeatable prescriber

YES2 none 2 2

Repeatable prescriptionwas signed more than6mths previously &presented for 1st

dispensing

YES

2 none 2 2Repeatable prescriptionwas signed more than 1yrpreviously

YES

2 none 2 2Expiry date on repeatableprescriptionhas passed

YES2 none 2 2

CP has beeninformed byrepeatable prescriber thatthe prescriptionis nolonger required

YES

2 none 2 2

ToS - 10(g) Do you have secure storagefor repeat prescriptions & YES 1 none n/a 1

8/8/2019 CPAF 2010-12

6/22

6


Rating



By

whom

By

when

PCT commentsFinal

Rating

S4BH - C20 batchissues?

ToS - 10(i)

S4BH - C4, D1

Do you keep records ofsupplies made againstrepeatable prescriptions forauditing? YES 1 none n/a 1

ToS - 10(k)S4BH - C4, C22, D1

How many anonymisedrecords of patients who havebeenreferred back to theprescriberdo you haveavailable for monitoringpurposes? NUMBER 1 none n/a 1

ToS - 10(l)

S4BH - C6

How many anonymised

records ofnotifications toprescribers ofclinicallysignificant issuesdo you

have available for monitoringpurposes? NUMBER 1 none n/a 1

ToS 10(m)

S4BH - C6

How many anonymisedrecords ofnotifications toprescribers of patients who

have beenrefuseddo youhave available for monitoringpurposes? NUMBER 1 none n/a 1

8/8/2019 CPAF 2010-12

7/22

7

Essential Service 3 (ES3) Disposal of Unwanted Medicines

Acceptance, by community pharmacies, of unwanted medicines which require safedisposal from households & individuals. PCTs will need tohavein place suitable arrangements for thecollection & disposal of waste medicines from pharmacies.


Rating



By

whom

By

when

PCT commentsFinal

Rating

ToS - 13(1)

S4BH - C4, D1

Do you have an SOP?

(Not mandatory) YE

S

2none n/a

2Does it have a review date? YES 2 none n/a 2Is it signed by all relevantstaff? YES

2none n/a

2If thereis an SOP, does itcover:

y Receipt

y Handling

y Storage

y Segregationinto

Hazardous & Non-hazardous

y Recordkeeping

y Controlled Drugs

y Disposalof returned, unwanted orexpired medicines? YES (tick) 2 none n/a 2

ToS - 14(a)

S4BH - C11

Have staff been trained, inorder to protect themselvesand others from harm, and to

protect theenvironment? YES 1 none n/a 1

ToS - 14(b)

S4BH - C21

Do you have protectiveequipment such as:

y Gloves

y Overalls

y Safety goggles YES (tick)

8/8/2019 CPAF 2010-12

8/22

8


Rating



By

whom

By

when

PCT commentsFinal

Rating

and materials to deal withspills?

Do you have a controlleddrug denaturing kit available? YES 1 none n/a 1

ToS - 13(3)(b)

S4BH - C4

Do you have a suitable bin/s

(where segregationisrequired) for unwantedmedicines, whichis / arestored safely? YES 1 none n/a 1

Do you accept sharps?(Should only do so ifparticipating in NeedleExchange Scheme) YES or NO 1 none n/a 1

ToS - 13(3)(c)

S4BH - C4

How frequently are unwantedmedicines collected?

(Should bequarterly) Quarterly 1 none n/a 1Do you retainconsignmentnotes / waste transfernotesfor at least 3 years? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

9/22

9

Essential Service 4 (ES4) Promotion of Healthy Lifestyles

The provision of opportunistichealthy lifestyle & publichealth advice to patients receiving prescriptions who appear to havediabetes; or be atrisk ofcoronary heart disease , especially those with high blood pressure ; or who smoke; or areoverweight, & pro-active participation in

national/local campaigns, to promote publichealth messages to general pharmacy visitors during specific targetedcampaign pe riods.


Rating



By

whom

By

when

PCT commentsFinal

Rating

ToS - 16(1)

S4BH - C16, D2

Do you have an SOP?(Not mandatory) YES 2 none n/a 2Does it have a review date? YES 2 none n/a 2Is it signed by all relevantstaff? YES 2 none n/a 2If thereis an SOP, does itinclude giving health adviceon the following?:

y stopping smoking

y alcohol intakey diet & nutrition

y exercise

y weight YES (tick) 2 none n/a

2

ToS - 16(2)

S4BH - C16Do you havehealthpromotion leaflets available? YES 1 none n/a 1

ToS - 16(3)

S4BH - C22, D9, D13

How many anonymisedrecords of advice givendoyou have available for

monitoring purposes? NUMBE

R 1 none n/a 1ToS -17(1)

S4BH - C22, D13

Did you participatein thePCTs sexual healthcampaignin July 2009? YES 1 none n/a 1

Did you participatein thePCTs flucampaigninNovember2009? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

10/22

10


Rating



By

whom

By

when

PCT commentsFinal

Rating

Did you participatein thePCTs stop smokingcampaignin January 2010? YES 1 none n/a 1

Did you participatein thePCTs vascular risk

campaignin March2010? YE

S 1 none n/a 1

8/8/2019 CPAF 2010-12

11/22

11

Essential Service 5 (ES5) - SignpostingThe provision ofinformation to peoplevisiting the pharmacy, who require further support, advice or treatment whichcannot b e provided bythe pharmacy, on otherhealth & social care providers or support organisations who may be able to assist the person. Where appropriate, thismay take the form of a referral.


Rating



By

whom

By

when

PCT commentsFinal

Rating

ToS - 19(1)

S4BH - C6, D2, D13

Do you have an SOP?(Not mandatory) YES 2 none n/a 2Does it have a review date? YES 2 none n/a 2Is it signed by all relevantstaff? YES 2 none n/a 2Do you have a list of otherhealth & social care providersto whom you may signpostpatients, including PALS? YES 2 none n/a 2

ToS - 19(1)S4BH - C6, C16, C18,D1, D2

Ifno SOP, how do youensure that staffknow who torefer patients to when thepharmacy is unable toprovide the advice, treatmentor support itself? TEXT

ToS - 19(2)

S4BH - C22, D9Do you use written referralforms, in appropriatecases? YES 1 none n/a 1

ToS - 19(3)

S4BH C22, D9

How many anonymised

records ofinformation givenor referrals madedo youhave available for monitoringpurposes? NUMBER 1 none n/a 1

8/8/2019 CPAF 2010-12

12/22

8/8/2019 CPAF 2010-12

13/22

13

Essential Service 8 (ES8) Clinical Governance (CG)

Clinical governanceis a framework through which NHS organisations are accountable forcontinually improving thequality of t heirservices and safeguarding high standards ofcare by creating anenvironment in whichexcellenceinclinical care will flouris h.There are 7 key components: patient and publicinvolvement; clinical audit; risk management; clinical effectiveness programmes;staffing and staff management; education, training andcontinuing professional and personal development; and use ofinformati onto support clinical governance andhealthcaredelivery.

Service Indicators Visit Questions Visit AnswersVis

it

Rating

Agreed Action

to reachCompliance (1)

Recommendation

to reachBest Practice (2)

By

who

m

By

when

PCT commentsFin

al

Rating

ToS - 26 (2)(a)(vii)

S4BH - C6, D2Thank you forco-operatingwith ourvisit. YES 1 none n/a 1

ToS - 26(2)(c)(vi) Who is your CG lead? NAME 1 none n/a 1

Patient & public involvement

ToS - 26(2)(a)(i)

S4BH - C16, C18, D3

Do you have a pharmacypractice leaflet, containing the

requiredinformation? YES 1 none n/a 1ToS - 26(2)(a)(ii)

S4BH - C16

How do you publish NHSservices from the pharmacy?

y Practice leaflet

y Window

y Website YES (tick) 1 none n/a 1

ToS - 22(2)(a)

S4BH - C16, C19

Are your pharmacy openinghours displayed? YES 1 none n/a 1

Do you display PCTnoticesof other pharmacies who areopenduring your out ofhoursperiod? YES 1 none n/a 1

ToS - 26 (2)(a)(iii)

S4BH - C7, C13, C14,C16, C17, C21, D1, D3,

Have you carried out the2009/10 CommunityPharmacy PatientQuestionnaire (CPPQ)? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

14/22

14


Rating



By

whom

By

when

PCT commentsFinal

Rating

D8, D11 Have you sent the CPPQfeedback summary to thePCT? YES 1 none n/a 1

Which areas ofimprovementwereidentified (if any)?

y ES1 Dispensing

y ES3 Disposal

y ES4 Health Promotion

y ES5 Signposting

y ES6 Self Care

y ES8 Clinical Governance (tick)

Have you taken any action toimprove performance? YES 1 none n/a 1

ToS - 26 (2)(a)(v)

S4BH - C1, C13a, C14,C17, D8, D11

Have you appointed aResponsible Person to deal

withcomplaints?(New regulation April 2009) YES 1 none n/a 1

Do you have a ComplaintsSystem in place? YES 1 n/a none 1

Do you have an SOP? YES 2 n/a none 2

Does it have a review date? YES 2 none n/a 2

Is it signed by all staff? YES 2 none n/a 2

Do you have a ComplaintsLeaflet outlining the

procedure to members of thepublic? YES 2 n/a none 2

Do you maintain aComplaints Record, includingany findings made & anyactions taken? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

15/22

15


Rating



By

whom

By

when

PCT commentsFinal

Rating

Did you publish & send yourAnnual Complaints Report tothe PCT for2009/10?(New regulation April 2009) YES 1 none n/a 1

ToS - 26 (2)(a)(vi)

S4BH - C6, C17, D2,D11

Have you beenvisited by thelocal Patient & Public (PPI)Forum? YES 1 none n/a 1

If yes, did you receive areport? YES 1 none n/a 1

ToS - 26 (2)(a)(viii)

S4BH - C18, C13, C18,C20, C21, D11, D12

Do you assess & reviewaccess arrangements to yourpharmacy by disabledcustomers? YES 1 none n/a 1

Do you carry outassessments of patients, &

keep these together withrecords of adjustments madein thecourse of supplyingmedicines (e.g. MDSdossetts)? YES 1 none n/a 1

Clinical audit

ToS - 26 (2)(b)

S4BH - C5d, D2

Did you carry out yourpharmacy based auditin2009/10? YES 1 none n/a 1

Did you participatein the

PCTs pharmacy ledmultidisciplinary audit onOral Methotrexatein2009/10? YES 1 none n/a 1

Risk management

ToS - 26(2)(c)(i) Do you have an SOP YES 2 n/a none 2

8/8/2019 CPAF 2010-12

16/22

16


Rating



By

whom

By

when

PCT commentsFinal

Rating

S4BH - C4, D1 covering appropriateprocurement & handling ofstock? (Not mandatory)

ToS - 26(2)(c)(ii)

S4BH - C4

Do you have servicecontracts for the regularmaintenance ofequipmentusedin the provision ofpharmaceutical services? YES 1 none n/a 1

Do you have anincidentreporting process in place torecord & considercriticalincidents in your pharmacy? YES 1 none n/a 1

Do you haveinternet accessto allow on-line reporting tothe NPSA? YES 2 n/a none 2

Do you have any experienceof reporting any criticalincidents to the NPSA? (Notnecessarily in your ownpharmacy) YES 2 none n/a 2

As a result of a criticalincident/near miss, is thereany learning that you canshare with us? YES 2 none n/a 2

ToS - 26(2)(c)(v)S4BH - C13ToS - 10(j)S4BH - C13

Do you have a shredder for

thedisposal ofconfidentialwaste & surplus batchissuesrelating to repeatableprescriptions? YES 1 none n/a 1

ToS - 26(2)(c)(vii)Have you and your staff beentrained onchild protection? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

17/22

17


Rating



By

whom

By

when

PCT commentsFinal

Rating

S4BH - C2 If yes, evidence of whichtraining do you have?:

y RPSGB training

y PCT training YES (tick) 1 none n/a 1

Do you have the following?:

y

Contact details of localchild protection officers

y Child protection poster YES (tick) 1 none n/a 1

ToS - 26(2)(c)(viii)

S4BH C4

Do you carry out a Health &Safety Risk Assessment? YES 2 none n/a 2

Do you carry out a Fire RiskAssessment? YES 2 none n/a 2

Clinical effectiveness programmes

ToS - 26(2)(d),

S4BH - D2, C7

Do you haveclinicaleffectiveness systems in

place to improve medicinesconcordance & to reducewastage? YES 1 none n/a 1

Do you have an up-to-date

information reference source,e.g. BNF, Drug Tariff? YES 1 none n/a 1

Do your staffknow how touse the sourceeffectively? YES 1 none n/a 1

Do your staffknow when torefer to the pharmacist? YES 1 none n/a 1

How do you quality assurethe advice your staff give toyourcustomers?

y Observe staff

y Staff observepharmacist YES (tick) 1 none n/a 1

8/8/2019 CPAF 2010-12

18/22

18


Rating



By

whom

By

when

PCT commentsFinal

Rating

y Role plays

y Train staff

Staffing & staff management / Education, training & continuing professional & personal development

ToS - 26 (2) (e) (iii)

S4BH - C10

Do you havecopies ofpharmacist & staff

qualifications for monitoringpurposes? YES 1 none n/a 1

ToS - 26 (2) (e)(i)

S4BH - C11

Do you have a writteninduction programme for yourstaff & locums? YES 1 none n/a 1

ToS - 26 (2) (e)(ii)

S4BH - C11

Do you have trainingprogrammes in place for yourstaff, appropriate to theirroles? YES 1 none n/a 1

Do you have records &

certificates of training for allmembers of staff formonitoring purposes? YES 1 none n/a 1

ToS - 26 (2)(e)(iv)

S4BH - C11

How do you identify trainingneeds of your staff?

y Opportunistically inthe workplace

y Upon staff request

y Peer review

y Team meetings YES (tick) 1 none n/a 1

How do you identify yourtraining needs?

y Opportunistically inthe workplace

y Peer review

y Team meetings YES 1 none n/a 1

8/8/2019 CPAF 2010-12

19/22

19


Rating



By

whom

By

when

PCT commentsFinal

Rating

Do you record any CPD thatyou have undertaken? YES 2 n/a none 2

ToS - 26(2)(e)(v)

S4BH - C11, D7

Do you have a process foridentifying, addressing &rectifying poor performance? YES 1 none n/a 1

Use of information to support clinical governance & health care delivery

ToS - 26(2)(f) (i)

Does your PMR system holdaccurate & appropriatepatient information that issecure? YES 1 none n/a 1

ToS - 26(2)(f)(ii)(iii)(iv)

S4BH - C13, C20

Do you have arrangements inplace to deal with requestsmade by patients for accessto informationheld by thepharmacy about themselves?

(Subject access requests) YES 1 none n/a 1Have you and your staffundertaken training on theData Protection Act 1998, theNHS Code of Practice onConfidentiality, and Human

Rights? YES 1

Train. SeePSNC contractworkbook,appendix 9:Briefing on

Confidentiality n/a 1

Do you haveconfidentialityclauses signed by eachmember of staff? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

20/22

20

Advanced Service - Medicines Use Review (MUR) & Prescription Intervention ServiceThis serviceincludes MURs undertaken periodically, as well as those arising in response to theneed to make a significant prescriptioninterventionduring thedispensing process. MUR is about helping patients use their medicines moreeffectively. Recommendations made toprescribers may also relate to theclinical orcost effectiveness of treatment.


Rating



By

whom

By

when

PCT commentsFinal

Rating

SD - 3(3)

S4BH - C11

Have you sent copies of MURcertificates for all pharmacistswishing to provide thisservice, to the PCT? YES 1 none n/a 1Have you completed a Prem1form & sent a copy to thePCT? YES 1 none n/a 1Do you have an SOP?(Not mandatory) YES 2 n/a none 2Does it have a review date? YES 2 n/a none 2Is it signed by all relevantstaff? YES 2 n/a none 2

SD - 3(4)

S4BH - C20, D12

Does your pharmacy have aconsultation area that meetsthe following national criteria:

y It is clearly designated

y It has seating forpharmacist & patient

y Conversations at normal

speaking level cannot beoverheard YES (tick) 1 none n/a 1

Do you everconduct MURs inthe public part of thepharmacy when the premisesareclosed? YES n/a n/a n/a n/a n/a n/a n/a

8/8/2019 CPAF 2010-12

21/22

21


Rating



By

whom

By

when

PCT commentsFinal

Rating

SD - 3(4)

S4BH - C18, C20, D11,D12

Have you obtained PCTconsent (using the PSNCapplication form) to undertakeany MURs away from thepremises, or by telephone? YES 1 none n/a 1

SD 3(6)(e) & (f)

S4BH - C5, D2

Do you only offer MURs to

patients who have been usingyour pharmacy for at least 3months? YES 1 none n/a 1Do you only offer MURs topatients oncein a 12 monthperiod? YES 1 none n/a 1

SD - 3(6) How many MURs have youundertakenin the financialyear to date? NUMBER 1 none n/a 1

SD 3(6)(g)S4BH - C6, D2c, D10

Of those, how many wereundertakenin the patientgroups identified by the PCT?(Only applicable to 4 MURpilots)

n/aNUMBER 2 none n/a 2

SD 3(6)(h), 3(7)

S4BH - C9

Do you use the Secretary ofState approved form forrecording each MUR? YES 1 none n/a 1

SD 3(6)(i)S4BH - C9

Do you always send a copy ofthe MUR form to the GP,

even whenno actionisneeded, as well as handing acopy to the patient? YES 1 none n/a 1

SD 3(6)(j)

S4BH - C9Do you keep a copy of theMUR form for2 years? YES 1 none n/a 1

8/8/2019 CPAF 2010-12

22/22

22

Documents

CPAF 2010-12