MMSOP76 HIV Homecare delivery by Provide Community

HIV Homecare Medicines Delivery Services Policy (SOP)

Document Control Information

Version: 1.0

Version Date: April 2024

Version Approved By: Performance & Governance Committee (12-14 Pharmacy Limited) Medicines Governance Safety Group (Provide Community Interest Company)

Author: Safil Walji (12-14 Pharmacy Limited)

Nisha Desai (Provide Community Interest Company)

Date Approved: April 2024

Review Date: April 2027

Monitoring Committee: Performance & Governance Committee 12-14 Pharmacy Limited Medicines Governance Safety Group (Provide Community Interest Company)

Target Audience: Staff at 12-14 Pharmacy Ltd and Provide Community who are currently involved in the provision of the Homecare Medicines Delivery Service or who are planning to be so.

Equalities Impact Assessment: 12-14 Pharmacy Limited strives to ensure equality of opportunity for all service users, local people, and the workforce. As an employer and a provider of health care, 12-14 Pharmacy Limited aims to ensure that none are placed at a disadvantage as a result of its policies. This policy has therefore been equality impact assessed to ensure fairness and consistency for all those covered by it regardless of their individuality.

Summary of key points in this document

• For the purposes of this policy, the term ‘Homecare Medicines Delivery Service’ will be used to describe the service that regularly delivers medicine supplies directly to a patient’s choice of location.

• This policy provides a framework for the management of the Homecare Medicines Delivery Service. It is a critical component of the management of risk and governance framework for 12-14 Pharmacy Ltd and Provide Community Interest Company, their patients, and staff.

• The purpose of this policy is to promote the provision of a high-quality Homecare Medicines Delivery Service to the patients under the care of Provide Community Interest Company.

• This policy has been written to reflect national guidance on the mechanisms by which medicines are supplied via a Homecare Medicines Delivery Service.

• This policy identifies the process, roles and responsibilities of staff groups and monitoring of the service

1. Introduction

1.1 This document sets out the process, roles and responsibilities in relation to the provision of Homecare Medicine Delivery Services delivered by 12-14 Pharmacy Ltd

1.2 It has been developed in line with recommendations made in the Homecare medicines report, “Towards a Vision forthe Future” written by Mark Hackett (formerly Chief Executive University Hospital Southampton NHS Foundation Trust) which was published in December 2011 by the Department of Health.

1.3 It applies to all staff members involved in any aspect of providing the Homecare Medicines Delivery Service to patients.

1.4 Homecare Medicines Delivery Services regularly delivers selected medicines directly to a patient’s home or to other agreed location.

1.5 The aim of the Homecare Medicines Delivery Service is to improve patient care by providing increased patient choice and accessibility to medicines, and to promote efficient use of resources.

1.6 Only medicines commissioned to be prescribed for the care of patients living with HIV are available via the Homecare Medicines Service.

2. Purpose

2.1 To identify the roles and responsibilities of all parties involved in the provision of the Homecare Medicines Delivery Service within 12-14 Pharmacy Ltd and Provide Community Interest Company Clinics

2.2 To outline the procedures for the provision of the Homecare Medicines Delivery Service to patients at Provide Community Interest Company Clinics

2.3 To promote standardisation of clinical and financial governance processes for the provision of the Homecare Medicines Delivery Service across 12-14 Pharmacy Ltd and Provide Community Interest Company.

2.4 To ensure that the 12-14 Pharmacy Ltd Homecare Medicines Delivery Service and associated procurement activities comply with current legislation and national guidelines.

3. Scope

3.1 The policy applies to all situations where medicines are, or are planned to be, delivered directly for patient use at home, or other address as authorised by them.

4. Duties and responsibilities

a. HIV Chief Pharmacist (12-14 Pharmacy Ltd)

4.1.1 Overall responsibility for all Homecare activities within 12-14 Pharmacy Ltd ensuring that arrangements for procurement and supply of Homecare medicines are in line with local and national polices.

b. Members of the Provide Community Interest Company Clinics

4.2.1 Assessing and deciding on the individual therapy plan for the patient.

4.2.2 Assessing and deciding if a patient is eligible for the Homecare Medicines Delivery Service and, if so, for registering and consenting the patient, and prescribing the medicines in line with this policy.

4.2.3 Ensuring that the patient is aware of their responsibilities in the Homecare Patient Charter (see Appendix 3) and providing the patient with a copy of this

4.2.4 Providing the patient with the Patient Guide (see Appendix 4) which details information about the Homecare Medicines Delivery Service

4.2.5 Ensuring that the patient is aware of the complaints process for Provide Community Interest Company and 12-14 Pharmacy Ltd

4.2.6 Providing advice and information to patients to ensure they understand all aspects of the Homecare Medicines Delivery Service and that they understand their responsibilities. The patient should also be provided with relevant information on how to contact their Provide Community Interest Company clinic and Homecare Provider should they need to (see Appendix 4)

4.2.7 Submitting the completed patient Homecare Medicines Registration and Consent form, and all other relevant documentation, to 12-14 Pharmacy Ltd by email to: acorn.pharmacy@nhs.net

4.2.8 Notifying 12-14 Pharmacy Ltd of any concerns from the patient or incidences in relation to the Homecare Medicines Delivery Service:

• Any incidences or complaints should be reported on the Complaints/Incidences Report Form (see Appendix 5) and the completed form sent to: acorn.pharmacy@nhs.net.

4.2.9 Generating prescriptions as needed, ensuring they are sent to 12-14 Pharmacy Ltd in a timely manner to avoid delay in processing and delivery to the patient:

• Wherever possible, prescriptions should be sent to 12-14 Pharmacy Ltd at least 14 days in advance of delivery to the patient being required:

• When delivery is requested outside the normal schedule i.e., within 14 days of receipt by 12-14 Pharmacy Ltd, agreement from 12-14 Pharmacy Ltd should be obtained for this

• Prescriptions for Homecare that are required for delivery within 5 working days of receipt will be subject to an emergency delivery surcharge.

4.2.10 Seeking approval from Provide Community Interest Company for prescriptions requiring delivery outside Suffolk or the catchment area as detailed in Appendix 1.

• Such prescriptions will be subject to a surcharge based on mileage to and from the delivery location

4.2.11 Informing 12-14 Pharmacy Ltd if a decision is made to stop the Homecare Medicines Delivery Service by completion of the Patient Deregistration Form (See Appendix 6) and sending this to 12-14 Pharmacy Ltd by email to: acorn.pharmacy@nhs.net

4.3 12-14 Pharmacy Ltd

4.3.1 12-14 Pharmacy Ltd is responsible for ensuring that all processes for the provision of Homecare medicines are safe, efficient, and cost-effective.

Duties carried out by the Homecare Medicines Delivery Service team include:

4.3.2 Implementing and maintaining Homecare services which comply with relevant legislation and guidance

4.3.3 Ensuring all Homecare arrangements comply with the Provide Community Interest Company medicines policies

4.3.4 Ensuring that procurement of Homecare medicines is in accordance with local and national contracts.

4.3.5 Carrying out clinical screening of prescriptions for Homecare medicines to ensure safety and appropriateness of the prescription.

4.3.6 Contacting patients to arrange deliveries of Homecare medicines within 5 working days from receipt of the prescription and in accordance with the delivery schedule.

4.3.7 Informing Provide Community Interest Company:

• at least 2 working days in advance of the due date for delivery of any failure to contact a patient to arrange delivery.

• of any failed deliveries to patients within 1 working day of the scheduled delivery. 12-14 Pharmacy Ltd should document these actions on the patient’s electronic record.

4.3.8 Processing invoices and ensuring that these are checked against proof of delivery (PODs) and are appropriately coded and passed on to Provide Community Interest Company within the agreed timeframe.

4 3.9 Dealing with administrative queries from Provide Community Interest Company clinic staff pertaining to delivery of Homecare medicines

4.3.10 Passing on the following information to the responsible teams at Provide Community Interest Company:

• Any clinical queries or issues raised by patients or 12-14 Pharmacy Ltd staff

• Requests from patients for prescriptions

• Any changes to patient details of which 12-14 Pharmacy Ltd are informed e.g. address, contact details

• Inability to contact the patient to arrange delivery

• Instances of failed delivery

• Requests from patients to discontinue receiving their medicines via the Homecare Medicines Delivery Service

• Any other relevant information

A note should be made on the patient’s electronic record by 12-14 Pharmacy Ltd of any action taken.

4.3.11 Being accountable for the appropriate storage of medicines to be supplied via the Homecare Medicines Delivery Service as per the product licence.

4.3.12 Providing up-to-date information to Provide Community Interest Company about stock levels when requested.

4 3 13 Ensuring that 12-14 Pharmacy Ltd’s contact details are up–to-date and informing Provide Community Interest Company clinics and patients of any changes of these details

4.3.14 Providing feedback on the service as part of service quality monitoring. This will be done through the Patient Satisfaction Survey and audited complaint forms and incident reports.

4.3.15 Informing Provide Community Interest Company of any issues and reporting any complaints and incidents.

4.3.16 Informing Provide Community Interest Company of any supply issues which may include shortages, MHRA alerts and recalls.

• 12-14 Pharmacy Ltd must inform Provide Community Interest Company of any brand switch in event of shortages and seek approval prior to substitutions being made.

4.3.17 Responding to any queries raised by NHSE via Provide Community Interest Company in a timely manner.

4.3.18 Monitoring of KPIs for the Homecare Medicines Delivery Service and meeting the guidelines required for reporting set out by Provide Community Interest Company and NHS England

4.3.19 Horizon scanning for potential opportunities for Homecare Medicines Delivery Services.

4.4 Finance

4.4.9 12-14 Pharmacy Ltd will invoice Provide Community Interest Company and provide the relevant prescribing data monthly as contractually agreed to facilitate the accurate submission of data by Provide Community Interest Company to NHSE

4.4.10 12-14 Pharmacy Ltd will ensure reporting of all contractual information is maintained in a timely manner.

5 Homecare Medicines Delivery Services

Decision to use homecare medicines delivery service for individual patient made by Provide Community and patient 'Patient given copy of Patient Charter and Patient Guide

Registration and consent form completed and emailed to 12-14 Pharmacy Ltd at: acorn.pharmacy@nhs.net and scanned into Electronic Patient Record

Patient Registered for Homecare Medicines Delivery Service

Patient prescription generated and emailed to 12-14 Pharmacy Ltd at: acorn.pharmacy@nhs.net

Original prescription put in sealed Envopak and given to 12-14 Pharmacy Ltd drivers Prescription received and entered onto the electronic tracker

Patient contacted to schedule delivery time/date and to confirm address and signatory, within 5 working days of receipt of prescription.

patient cannot be contacted within 48 hours of required delivery date, to contact Provide Community for advice.

6. Initiating the Homecare

Medicine Service

6.1 An assessment of suitability for Homecare must be undertaken before proceeding and registering patients on the Homecare Medicines Delivery Service Consideration needs to be given to issues such as patient adherence, history of attendance, language barriers, disabilities, and contactability.

6.2 The decision to offer a patient the Homecare Medicines Delivery Service should be part of a multidisciplinary approach involving the patient and the responsible clinician(s) at Provide Community Interest Company clinic.

6.3 It is required that all Homecare Medicines Delivery Services will follow the normal medicine governance and procurement procedures within Provide Community Interest Company including formulary controls and Medicines policies.

6.4 A patient must fully understand the benefits and risks of the Homecare Medicines Delivery Service. Patients preferring to receive their medicines directly from the clinic should not be prevented from doing so. Prior to the Homecare Medicine Delivery Service being initiated, a patient must provide formal written consent by completing and signing a patient Registration and Consent Form (see Appendix 2). An authorised representative may act as a signatory where appropriate. The patient is able to change their mind about participation in the service without prejudice and affecting their care at any time

6 5 The Homecare Patient Charter and Patient Guide must be made available to all patients being commenced on the Homecare Medicines Delivery Service (see Appendices 2 and 3)

7.1 12-14 Pharmacy Ltd is requiredto have agreed clinical governance systems that can be integrated with Provide Community Interest Company policies in order to ensure that all conditions that relate to KPIs set by Provide Community Interest Company are being met:

• Additional KPIs can be agreed, and existing KPIs altered, especially if Provide Community Interest Company becomes dissatisfied with the service of 12-14 Pharmacy Ltd and/or should the service model change.

7.2 12-14 Pharmacy Ltd will comply with all relevant current regulatory conditions and frameworks as would be required by the Care Quality Commission (CQC). This policy forms part of 12-14 Pharmacy Ltd’s CQC policies concerning homecare.

7.3 12-14 Pharmacy Ltd will deliver training and education on induction of their staff to those involved in any aspect of the homecare service to ensure the appropriate implementation of policies and clinical governance of the Homecare service. Further training/education needs about homecare services will be identified by 12-14 Pharmacy Ltd’s Performance & Governance Committee and delivered by 12-14 Pharmacy Ltd to their staff accordingly.

7.4 12-14 Pharmacy Ltd will provide quarterly service delivery reports as specified in Section 6A of its contract to ensure operational management and that the service specification is met.

7.5 A report of complaints, adverse incidents, service failures, patient satisfaction and other relevant issues will be produced by 12-14 Pharmacy Ltd in a format that can be integrated with the Provide Community Interest Company clinical governance reporting systems and reported to them.

7. 12-14 Pharmacy Ltd’s Governance Processes and Monitoring

7.6 Unless otherwise agreed, findings of any investigation as result of any complaint/incident defined above will be issued within 14 working days to Provide Community Interest Company, if appropriate, and to the patient

7.7 Any communication with the patient regarding outcomes of investigations must be made available to Provide Community Interest Company prior to 12-14 Pharmacy Ltd informing the patient.

7.8 In order to monitor the effectiveness of the service received by the patient, 12-14 Pharmacy Ltd will periodically send feedback forms to patients and report the responses received to Provide Community Interest Company as part of its quarterly reporting.

8. Ratification

This policy will be approved by the Performance & Governance Committee for 12-14 Pharmacy Ltd and Provide Community Interest Company

9. Distribution

This policy will be available to relevant 12-14 Pharmacy Ltd and Provide Community Interest Company staff

10. References

10.1 Royal Pharmaceutical Society. Professional standards for Homecare services in England (September 2013) Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Profession al%20standards/Professional%20standards%20for%20Homecare%20services/homecarestandards-final-sept-13.pdf

10.2 Department of Health (2011), Homecare medicines ‘Towards a vision for the Future’ December 2011 (Hackett report). Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213112/111201Homecare-Medicines-Towards-a-Vision-for-the-Future2.pdf

10.3 Royal Pharmaceutical Society. Handbook for Homecare Services in England. May 2014. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Profession al%20standards/Professional%20standards%20for%20Homecare%20services/homecareservices-handbook.pdf

Appendix 1: Map of catchment area for the Home Delivery Service

Appendix 2: Patient registration and consent form

Provide Community Clinic Name

PART

1 – Patient Details

Any other comments:

Alternative

delivery address Alternative signatory

Name

Relationship to patient

Contact details

If another person is accepting deliveries, they must be:

• notified of the delivery in advance

• over 16 years of age

• able to accept responsibility for the delivery

Preferred delivery day (Monday – Friday)

Preferred delivery time AM (7.30am-12.00 noon) PM (12.30pm-5.00pm)

Patient Consent

• I have been informed of the details of the homecare medicines delivery service and consent to have my medicines supplied by 12-14 Pharmacy Ltd via this service. I understand that I must still attend my regular appointments so that my health is monitored, and my clinical team can provide the appropriate prescriptions.

• I accept that if I cannot comply with the homecare medicines delivery service requirements then I will need to attend the clinic to collect my medicines

• I agree that 12-14 Pharmacy Ltd may occasionally contact me to obtain feedback of the service.

• I understand that the confidentiality of my personal information will always be maintained and be processed in accordance with my rights under the Data Protection Act.

• I understand that I can withdraw from the service any time, and this will not affect my treatment.

Patient/Representative

Name:

Patient/Representative

Signature:

PART 2 – Referring Healthcare Professional

Date:

I have discussed the service with the patient has and they have consented to receive their medicines via the homecare medicines delivery service provided by 12-14 pharmacy Ltd

Name:

Position:

Phone:

Signature:

Date:

Email:

Signed copy to be scanned and emailed to 12-14 Pharmacy Ltd, 9 Flag Business Exchange, Vicarage Farm Road, Peterborough, PE1 5TX. Original signed copy to be scanned into patient’s Electronic Patient Record

Appendix 3. Homecare Medicines Delivery Service: Patient Charter

What can you expect from 12-14 Pharmacy Ltd as a Homecare Medicines Delivery Service Provider?

Dignity and respect you deserve

12-14 Pharmacy Ltd as a Homecare Provider will always treat you politely and with the utmost dignity and respect. We will not treat you differently based on your age, gender, sexual orientation, any disability you may have, where you are from or what you believe.

The ‘right’ to be engaged and your choice matters

We are responsible for making the arrangements for the delivery of your medicines and you can expect us to do our best to accommodate you and your needs. However, we cannot guarantee we will be able to specifically cater for your requests. You can expect to have an explanation if your needs cannot be met and you can talk about this with us or your Provide Community clinical team if needed.

Working together

We work closely with your clinicians at Provide Community to make sure the provision of medicines runs as smoothly as possible. Provide Community still remains the provider of your care and if you are worried about your health, please contact your Provide Community clinic.

A confidential service

The confidentiality of your information is extremely important to us. We will maintain your personal data in accordance with General Data Protection Regulations and NHS patient confidentiality guidelines. We will do all we can to ensure your information is secure and that unauthorised access, loss, disclosure is prevented.

How can you assist us?

Respect our staff

Everyone who is supporting you with the safe delivery of your medicines – whether it is our drivers, pharmacists or our customer services team deserves - to be treated with respect. Anyone who verbally or physically threatens our staff may have their participation in the service removed immediately.

If things go wrong and/or you wish to complain

The Homecare Medicines Delivery Service should be of a high standard but errors can occurs and every patient has the right to raise concerns about the service they receive.

If you have a concern and/or believe an error has been made, please contact 12-14 Pharmacy Ltd or your Provide Community clinic immediately in order that this can be addressed; we and your Provide Community Team will strive to learn from any errors to minimise the chance of them happening again, so reporting them is important.

The Patient Guide details how to get in touch with us and how to make a complaint should you wish to.

Appendix 4. Patient guide for the homecare medicines delivery service

Why have I been given this leaflet?

You have been given this leaflet as your clinician considers it appropriate for you to have the choice to have your medicines delivered directly to your home or other address of your choosing. This is called a Homecare Medicines Delivery Service. This leaflet aims to provide you with the information you need to make an informed decision about whether you wish to receive your medicines via the Homecare Medicines Delivery Service and how this service works should you wish to proceed.

Should you wish to change your mind about participation in the Homecare Medicines Delivery Service and prefer to collect your medicines from the clinic instead, you may do so at any time without prejudice or affecting your care in any way.

What is a Homecare Medicines Delivery Service?

With your consent, Provide Community will send your prescription to 12-14 Pharmacy Ltd, who will dispense the medicines and deliver them to you

Whilst you do not need to come to Provide Community to collect your medicines, you must still attend your routine clinic appointments, whether this be by teleconsultation, video consultation or face-to-face with your clinicians as your clinicians at Provide Community need to monitor your health effectively and ensure that your medicines are safe and appropriate for you You will not be able to continue receiving your medicines via this service without these check-ups.

How will the Homecare Medicines

Delivery Service work?

1. The Provide Community clinical team discuss the homecare option with you during an appointment.

2. If you wish to proceed, the Homecare Registration and Consent form is completed and sent to 12-14 Pharmacy Ltd.

3. When it is required, the Provide Community clinical team write your prescription and send this to 12-14 Pharmacy Ltd.

4. 12-14 Pharmacy Ltd contacts you to arrange delivery of your medicines

5. 12-14 Pharmacy Ltd clinically checks your prescription and it is dispensed under the professional supervision of a registered pharmacist

6. 12-14 Pharmacy Ltd delivers your medicines to the agreed address at the agreed date and time. The must be signed for by an authorised signatory.

Homecare Medicines Delivery Services are considered by the NHS as a safe and convenient method of supplying your medicines. Every endeavour will be made to ensure that your medicines reach you in good time and you do not run out. To minimise this risk your deliveries will be carefully managed and scheduled, and contingency plans are in place for emergency deliveries, as agreed with Provide Community. However, you can help by contacting your Provide Community clinic if you have less than 1 month’s medicine supply remaining and have not been contacted by 12-14 Pharmacy Ltd to arrange your next delivery

What are the delivery options?

After we have received your prescription from Provide Community, we will contact you to discuss when it will be convenient for your medicines to be delivered. You will be offered morning slots between 7.30am and 12.00noon or 12.30pm and 5.00pm Monday to Friday

The delivery must be signed for and you may nominate an authorised signatory to do this on your behalf should you wish to do so, as long as they are over 16 years of age and hold a form of identification in their name. You may also request that your medicines are delivered to an address other than your home, such as your place of work, should you wish.

It is your responsibility to make sure you are present as agreed, or to make arrangements for your authorised signatory to be at the nominated delivery address to receive your medicines, at the arranged date and time. Please contact 12-14 Pharmacy Ltd prior to the delivery if something unexpected arises and the delivery cannot be received.

You can expect to receive a discrete service. Medicines will be packaged such that the content of the package is not apparent, and deliveries will be made in an unmarked van. The staff who deliver your medicines will have been fully checked by the Disclosure and Barring Service (DBS) to ensure they do not have any criminal convictions and they will follow strict confidentiality guidelines.

Members of our staff will carry an identity badge to show who they are and you, or your authorised signatory, can expect, and request, to be shown this before accepting your medicines.

What happens if there is no-one to sign for my medicines or I/my nominated representative are not at home when my medicines are delivered?

You will have been contacted to arrange delivery at a time that is convenient for you/your authorised signatory. If you become aware you/they are unable to make this date and time, please let us know as soon as possible in order that we can rearrange to deliver at a more convenient time.

If you do not contact us and you/your authorised signatory are not present to receive your delivery, the delivery will be returned to 12-14 Pharmacy Ltd and your prescribing clinician at Provide Community will be notified. We will endeavour to try to rearrange delivery but your clinician will also need to consider if the Homecare Medicines Delivery Service is appropriate for you as you need to be able to commit to you, or your authorised signatory, being available to receive deliveries.

What information will 12-14 Pharmacy Ltd know about me?

Your personal details, including your name, home address, date of birth, contact details, medical condition and treatment will be held on the 12-14 Pharmacy Ltds highly secure computer network. 12-14 Pharmacy Ltd is bound by the same confidentiality rules as the NHS regarding accessible patient information (The Data Protection Act 1998).

12-14 Pharmacy Ltd will only contact you to discuss your treatment and the delivery of your medicines. They may share any relevant information with your clinical team at Provide Community.

What do I do if things go wrong or I wish to make a complaint?

It is important that you know who to contact if you have a concern. The contact details of 12-14 Pharmacy Ltd and Provide Community are provided below.

You should contact the 12-14 Pharmacy Ltd if:

• The delivery has not arrived at the agreed date and time

• You would like to change the agreed delivery date, time, address or authorized signatory

• You have any other query around the delivery of your medicines

• You would like to make a complaint about any aspect of the service received from 12-14 Pharmacy Ltd

• You change your contact details such as your address or telephone number

• You need to check for interactions between your medicines prescribed by Provide Community and any other medicines, including those you may purchase over-the-counter and any herbal or supplementary medicines such as vitamins or minerals:

• The 12-14 Pharmacy Ltd Medicines Information Helpline can be contacted on: 07704 602205 Monday-Friday 9am-5pm.

You should contact your Provide Community Team if:

• You feel your condition managed by Provide Community is getting worse

• You feel generally unwell after taking your medicines prescribed by Provide Community

• You want to discuss your condition and/or your treatment

• You experience an unexpected side effect/adverse reaction potentially associated with your medicines prescribed by Provide Community

• If you have missed any doses of the medicines prescribed by Provide Community for any reason

• You change your contact details such as your address or telephone number

• You are running low on medicines supplied by Provide Community and have not been contacted by 12-14 Pharmacy Ltd to arrange a delivery

• You would like to make a complaint about any aspect of the service received from 12-14 Pharmacy Ltd and would like Provide Community to raise this on your behalf

If you wish to make a formal complaint, 12-14 Pharmacy Ltd or your clinical team at Provide Community can provide you with a Complaints Form to fill in. We aim to complete all investigations into any incident within 14 days and report our findings to Provide Community and to you, should you wish to be informed.

Contact details

12-14 Pharmacy Ltd

If you need to contact 12-14 Pharmacy Ltd, please call Customer Service: 0333 733 4111 (Option 4 – Homecare) or 01733 834772. These calls are charged at your standard rate.

Provide Community

If you need to contact your Provide Community Interest Company Clinic, please call: 0300 303 9982 and choose the appropriate options for the clinic you receive your care from.

Page 18 of 20

COMPLAINT AND INCIDENT REPORT FORM

This form can be completed by either the patient or their representative or a relevant member of staff involved in the patient’s care.

Patient Details

Patient Name &/or Clinic Number

Provide Clinic address

Name of reporter/person completing form:

Relationship to patient:

Telephone:

Email:

Date of Birth

Reporter Details

About the Complaint or Incident

Date complaint/incident occurred:

Date reported:

Describe what happened: (Do not use any personal identifiable data here. Instead for example say the patient, the hospital nurse or the customer service agent)

Does the patient wish to be informed of the outcome of the investigation? Yes No

Please email the completed form to 12-14 Pharmacy Ltd at: acorn.pharmacy@nhs.net and scan into the Electronic Patient Record.

Appendix 6.

PATIENT DE-REGISTRATION FORM

PATIENT DETAILS

Name:

Clinic Number:

Please de-register this patient from the Homecare Medicines Delivery service

Patient will be removed permanently from the service; to restart a stopped patient they will need to be re-registered as a “new” patient.

Reason for Discontinuation:

Date of Birth:

Requested date service to permanently cease:

Change Requested By (to be completed by Provide Community Interest Company)

Signature:

Name and Position/role: (please print)

Change Actioned By (to be completed by 12-14 Pharmacy Ltd)

Signature:

Name: (please print)

Date:

Please email the completed form to 12-14 Pharmacy Ltd at: acorn.pharmacy@nhs.net and scan into the Electronic Patient Record.