schedule 2 the services - psnc main...
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SCHEDULE 2 – THE SERVICES
A. Service Specifications
Mandatory headings 1 – 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement. All subheadings for local determination and agreement
Service Specification
No.
Service Think Pharmacy Urgent Palliative Care Medicines Service
Commissioner Lead NHS Vale Royal CCG
Provider Lead Superintendent Pharmacist
Period 1 April 2014 to 31 March 2017
Date of Review
1.1 National/local context and evidence base Patients who have been assessed as entering the last days of life require access to a set range of palliative care medicines in anticipation of need. Community pharmacists included in this service guarantee to continuously stock the medicines in the palliative care formulary so that patients can be assured of supply when required. The stock held for the Think Pharmacy Urgent Palliative Care Medicines Service should be over and above the core stock holding, and the CCGs agree to reimburse contractors should the medicines be held beyond their expiry date. This service:
Supports patients and their carers to access medicines that may be required for palliative care purposes in a location close to their home (or preferred place of death)
Avoids unnecessary hospital admissions where the sole purpose of admission is to access appropriate medicines
Supports pharmacies to hold palliative care medicines in stock
Provides assurance to commissioners that patients who require palliative care medicines will have access to the medicines during core hours from specified locations.
2. Outcomes
2.1 NHS Outcomes Framework Domains & Indicators
Domain 1 Preventing people from dying prematurely
Domain 2 Enhancing quality of life for people with long-term
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conditions
Domain 3 Helping people to recover from episodes of ill-health or
following injury
Domain 4 Ensuring people have a positive experience of care
Domain 5 Treating and caring for people in a safe environment
and protecting them from avoidable harm
2.2 Local defined outcomes
To improve access across the geographical area covered by the commissioners (NHS South Cheshire CCG, NHS Vale Royal CCG and NHS Eastern Cheshire CCG) for patients and health care professionals to Palliative Care medicines when they are required within normal pharmacy opening hours.
To guarantee continuous availability of formulary stock from named pharmacies for patients and health care professionals who require immediate / urgent access to palliative care medicines.
3. Scope
3.1 Aims and objectives of service
To continuously hold the range and quantity of medicines specified by the palliative care formulary and to dispense these in response to NHS prescriptions presented for the total number of hours the pharmacy is open
To have a process in place which ensures that all new staff, are aware of commissioned services provided by the pharmacy and maintain continuity of service during and after staff changes.
3.2 Service description/care pathway
The service provider must order and continuously hold the range and quantity of medicines specified by the formulary and will dispense these in response to NHS prescriptions presented. See Appendix 1
The service provider will provide the service for the total number of hours the pharmacy is open.
The stock for this service should be in addition to any stock holding the service provider would usually stock.
Expiry dates for this stock should be monitored to prevent waste; short dated stock should be rotated with the service provider’s usual stock holding.
Dispensed or date expired stock for this service must be replaced immediately.
The Commissioners will reimburse the cost of stock specifically purchased for this service that cannot be used and has reached its expiry date. This will be done by completing the Expired Stock Claims form. See Appendix 3
In the event of any significant availability issues concerning products required to be
kept in stock for this service the serviced provider must contact the Commissioner.
The service provider must telephone the next nearest service provider in advance
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to ensure that they are able to dispense the prescription before signposting a patient or carer.
The contract payment is for provision of a Think Pharmacy Urgent Palliative Care Medicines Service Payments will be made as follows.
- £200 annual fee for providing the service irrespective of the number of prescription items dispensed.
- The fee will be paid as a lump sum on the receipt of an annual declaration from the service provider of their intent to continue the service from the named community pharmacy
- Claims will be made and paid annually on submission of the declaration and invoice in Appendix 4.
Accreditation
Any registered pharmacist may dispense palliative care medicines on receipt of a valid prescription. Suggested training that may support this service. CPPE Care of the terminally ill – communicating with patients open learning.
Standard Operating Procedure
The service provider will have a Standard Operating Procedure (SOP) / protocol which specifically details the operational delivery of the Think Pharmacy Urgent Palliative Care Medicines Service in accordance with this specification.
The service provider must ensure that all staff working in the pharmacy have relevant knowledge, are appropriately trained and operate within protocols / SOPs, this includes understanding when to recommend the service to clients and using sensitive client-centred communication skills.
The SOP / protocol should be reviewed at least every two years or before if circumstances dictate. Each review should be documented and the SOP / protocol subject to version control. Staff must read, date and sign the SOP/protocol after a review.
Changes to procedure must be highlighted within the SOP / protocol for special attention.
The Standard Operating Procedure / protocol must be available to the commissioner if requested.
Record Management
Records maintained in association with this service must be available to the commissioner on request.
Service Continuity
It is the responsibility of the service provider to have a process in place that ensures that all new staff and locums are aware of the Think Pharmacy Urgent Palliative Care Medicines Service and must maintain continuity of service during and after staff changes.
The service provider has a responsibility to ensure that all staff members provide the service strictly in accordance with the service specification and Standard Operating Procedures.
If concerns are raised regarding the continuity of service provision the commissioner reserves the right to instigate discussions with the contractor, which could lead to termination of the contract
Complaints
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The service provider must have a complaints procedure that complies with Local Authority Social Services and National Health Service complaints (England) Regulations 2009.
Complaints directly linked to the quality of this service must be reported to the commissioner.
3.3 Population covered Patients resident within the geographical area covered by NHS Eastern Cheshire CCG, NHS South Cheshire CCG and NHS Vale Royal CCG who present a prescription for palliative care medicines are eligible for inclusion in the service. The total population is estimated to be as follows:
204,000 in Eastern Cheshire
176,000 in South Cheshire
103,000 in Vale Royal.
Equality and Diversity
The service provider must comply with the requirements of the Equality Act 2010, and will not treat one group of people less favourably than others because of age, disability, gender reassignment, marriage or civil partnership, race, religion or belief, sex or sexual orientation.
It is the responsibility of the service provider to make reasonable adjustments to meet the individual needs of their patients. Where providers are able to identify a cohort of patients for whom reasonable adjustments may be required, they should discuss this with the Commissioner.
3.4 Any acceptance and exclusion criteria and thresholds Community pharmacies must hold an NHS contract for the provision of Pharmaceutical Services. Pharmacies will be selected for inclusion in the service to provide sufficient coverage in each town /locality so that patients are not unduly inconvenienced when seeking to have their prescriptions for palliative care medicines dispensed.
3.5 Interdependence with other services/providers Community pharmacies are expected to liaise with out of hours / urgent care providers and general practice to facilitate access to the palliative care formulary medicines.
4. Applicable Service Standards
4.1 Applicable national standards (eg NICE) Supply of ALL medicines must be in accordance with the Human Medicines Regulations 2012. The commissioner and the commissioned service provider recognize that this service specification and/or associated recorded information may be subject to Freedom of Information Requests (FOI). Each party shall comply with any such Freedom of Information requests received, in accordance with the Freedom of Information Act 2000 legal obligations. The service provider shall comply with the requirements of the Health and Safety at Work Act 1974, the management of Health and Safety at Work Regulations 1999 and any other acts, regulation, orders or rules of law pertaining to health and safety. 4.2 Applicable standards set out in Guidance and/or issued by a competent body
(eg Royal Colleges) The Think Pharmacy Urgent Palliative Care Medicines Service may only be provided by
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Pharmacists with a current registration with the General Pharmaceutical Council from premises that hold a current contract to supply NHS Pharmaceutical Services.
4.3 Applicable local standards The Think Pharmacy Urgent Palliative Care Medicines Service shall be available during ALL of the community pharmacy provider’s core opening hours. Any medicines dispensed from the Palliative Care stock should be immediately replaced to ensure continuity of supply.
5. Applicable quality requirements and CQUIN goals
5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D])
Not Applicable
5.2 Applicable CQUIN goals (See Schedule 4 Part [E]) Not Applicable
6. Location of Provider Premises
The Provider’s Premises are located at:
7. Individual Service User Placement
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Appendix 1
Central and Eastern Cheshire Palliative Care Formulary
Emergency Palliative Care Drugs – Listed service providers in Central and Eastern Cheshire will always have this range and quantity of drugs in
stock
Health Care Professionals can access help via. the 24hr advice line numbers for Specialist Palliative Care Advice
South Cheshire and Vale Royal: 01606 551246 Eastern Cheshire: 01625 666999
Drug Form available Quantity Main indications in acute situation
Commoner acute
side-effects
Dosage
Diamorphine 5mg ampoule
10mg ampoule;
30mg ampoule;
100mg ampoule
5 ampoules
5 ampoules
5 ampoules
5 ampoules
Severe pain not controlled by weak opioid
Patient unable to take
morphine orally
Drowsiness (settles with time); nausea, vomiting (try metoclopramide or haloperidol); unsteadiness
Confusion, hallucinations (tolerance does not occur, reduce or change drug)
If no previous opioid –
5mg 4 hourly & prn, or 30mg/24h SC in syringe driver (half if frail)
If changing from oral morphine - 1/3 total daily morphine dose, given SC via syringe driver
The prn dose is 1/6 of 24h diamorphine dose
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Drug Form available Quantity Main indications in acute situation
Commoner acute
side-effects
Dosage
Morphine Sulphate
10mg ampoule;
30mg ampoule;
10 ampoules
10 ampoules
Severe pain - to be used as an alternative to diamorphine if diamorphine is not available
Drowsiness (settles with time); nausea, vomiting (try metoclopramide or haloperidol); unsteadiness
Confusion, hallucinations (tolerance does not occur, reduce or change drug)
If no previous opioid –
5mg-10mg 4 hourly & prn,
or 30mg-45mg/24h SC in syringe driver (half if frail)
If changing from oral morphine - 1/2 total daily oral morphine dose, given SC via syringe driver
If changing from SC diamorphine – 1.5 times total daily SC diamorphine dose, given SC via syringe driver
The prn dose is 1/6 of 24h morphine dose
Oramorph® 10mg/5ml
oral solution
100mg/5ml concentrated oral
solution
2 x 100ml
1 x 30ml
Severe pain not controlled by weak opioid
Drowsiness (settles with time); nausea, vomiting (try metoclopramide or haloperidol); unsteadiness
Confusion, hallucinations (tolerance does not occur, reduce or change drug)
Initially 10mg (5mg if frail) as needed 2 hourly, or depending on previous morphine dose
Breakthrough dose = 1/6 of regular 24h total morphine dosage
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Drug Form available Quantity Main indications in acute situation
Commoner acute
side-effects
Dosage
Diclofenac 100mg suppository 10 supps Inflammatory pain, especially bone pain, musculoskeletal pain
Occasional bronchospasm; nausea; dyspepsia
50-100mg stat;
150mg-200mg/day in divided doses
Cyclizine 50mg in 1ml ampoule
5 ampoules Nausea caused by pharyngeal stimulation, visceral distension or deformation, vestibular disturbance, raised intracranial pressure
Drowsiness, anti-muscarinic effects (blurred vision, palpitations, palpitations, arrhythmias, dry mouth, constipation, heartburn, urinary retention)
50 mg SC prn tds;
100-150mg/24h SC via syringe driver (may be increased to 300mg if needed and tolerated)
Haloperidol 5mg in 1 ml ampoule
5 ampoules a)Anti-emetic for chemical
or toxic causes
b)Agitation or acute
confusional state
Extra-pyramidal - including tardive dyskinesia, sedation, dry mouth, neuroleptic malignant syndrome
a) 1.5-5mg SC stat dose up to 6 hourly or 5-15mg per 24h via syringe driver
b) 1.5-5mg SC stat, then 5-30mg SC od to bd, or over 24h via syringe driver
Metoclopramide
10mg in 2ml ampoule
10 ampoules Nausea and vomiting due to gastric irritation or impaired emptying (stasis)
Extrapyramidal effects; neuroleptic malignant syndrome; sedation in high doses
10mg stat SC every 3-4 hours or 30-60mg/24h SC via syringe driver (up to 100mg on specialist advice)
Levomepromazine (methotrimeprazine)
25mg in 1 ml ampoule
10 ampoules Nausea and vomiting (broad spectrum)
Severe agitation, psychosis
Sedation;
postural hypotension;
extra-pyramidal
5-25mg SC once or twice a day in divided doses, or via syringe driver (stepwise to 300mg/24h if tolerated)
Midazolam 10mg in 2ml ampoule
10 ampoules Terminal agitation
Myoclonus
Seizures
Sedation; hypotension 2.5-10mg SC stat (10-20mg SC or slowly IV for repeated seizures); then 20-60mg/24h via syringe driver (up to 100mg/24h has been used)
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Drug Form available Quantity Main indications in acute situation
Commoner acute
side-effects
Dosage
Diazepam Rectal Solution
4mg/ml 2.5ml tube = 10mg
5 x 10mg tubes
Hyoscine Butylbromide
20mg in 1ml ampoule
5 ampoules Bowel colic obstruction
Moist, noisy breathing if patient is comatose
Anticholinergic (blurred vision, palpitations, palpitations, arrhythmias, dry mouth, constipation, heartburn, urinary retention); does not cross blood-brain barrier
20mg stat, then 60mg/24h via syringe driver, increasing to 120mg if needed (occasionally to 300mg in obstruction)
Glycopyrronium Bromide (Robinul
®)
200micrograms/ml ampoule
10 x 1ml ampoules
Bowel colic
Moist, noisy breathing if patient is comatose
Anticholinergic (blurred vision, confusion, palpitations, palpitations, arrhythmias, dry mouth, constipation, heartburn, urinary retention)
200-400micrograms SC repeated as needed every 3 hours
600-1200micrograms per 24 hours by SC infusion
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Drug Form available Quantity Main indications in acute situation
Commoner acute
side-effects
Dosage
Dexamethasone
2mg tablet 50 tablets Pain & symptom relief from raised intracranial pressure, spinal cord compression, liver capsule pain, nerve compression
Relief of pressure in superior vena caval obstruction, stridor, spinal cord compression
Adjunct to anti-emetic in resistant nausea
Acute - mental disturbance, impaired glucose tolerance, masking of symptoms of acute infection
8 to 16mg orally once daily
For acute spinal cord compression - where intervention is appropriate, give 16mg once to twice daily & admit urgently
Water for Injections
10ml ampoule 2 x 10 ampoules
Making up of diamorphine and diluting to correct volume for syringe driver
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Appendix 2 Think Pharmacy Urgent Palliative Care Service Providers in Central and Eastern Cheshire
TOWN / AREA PHARMACY NAME & ADDRESS CONTACT N0 OPENING HOURS
ALSAGER LLOYDS PHARMACY
25 Lawton Road Alsager ST7 2AA
01270 882049
(Tel. & Fax)
Mon-Fri 8.15am-6.30pm
Sat 9.00am-5.00pm
CONGLETON
Co-Op Healthcare Ltd
2 Mill Street Congleton CW12 1AB
01260 273200
(Tel. & Fax.)
Mon-Sat 9.00am-5.30pm
Sat 9.00am-1.00pm
CO-OP HEALTHCARE Ltd
1 Park Lane
Congleton CW12 3DN
01260 280810 (Tel.)
01260 273209 (Fax.)
Mon-Fri 8.45am-6.30pm
Sat 9.00am-1.00pm
Tesco In Store Pharmacy
Barn Road
Congleton
CW12 1LR
01260 205247(Tel) Mon 8. 00am – 10.30pm
Tue- Fri 6.30am – 10.30pm
Sat 6.30am – 10.00pm
Sun 10.00am – 4.00pm.
Boots UK ltd
Barn Road
Congleton CW12 1LR
01260 276977 (Tel)
01260 271057 (Fax)
Mon– Fri 8.00am – 12.00pm Sat 8.00am - 10.00pm
Sun 10.00am – 4.00pm
CREWE ASDA IN-STORE PHARMACY
Victoria Centre
Crewe CW1 2PT
01270 258271
(Tel. & Fax)
Mon 8.00am-11.00pm
Tues-Fri 7.00am-11.00pm
Sat 7.00am-10.00pm
Sun 10.00am-4.00pm
BOOTS UK LTD
56-58 Market Street
Crewe CW1 2EX
01270 212252 (Tel.)
01270 251319 (Fax)
Mon-Sat 9.00am-5.30pm
Tesco In Store Pharmacy
Vernon Way
Crewe CW1 2DD
01270 416647 (Tel)
01270 416449 (Fax)
Mon 8.00am – 10.30pm
Tue – Fri 6.30am – 10.30pm
Sat 6.30am – 10.00pm
Sun 10.00am – 16.00pm
Boots UK Ltd
Unit 12
01270 254702 Mon-fri 8.00am-12.00midnight
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Grand Junction Retail Parl
Crewe CW11 2RP
Sat 8.000am -10pm
Sun 11.00am – 5.00pm
DISLEY CO-OP HEALTHCARE Ltd
11 Fountian Square
Disley SK12 2AB
01663 762048
(Tel. & Fax)
Mon,Tues,Thur,Fri
9.00am-6.00pm
Wed, Sat 9.00-1.00pm
HANDFORTH CO-OP HEALTHCARE Ltd
110 Wilmslow Road
Handforth SK9 3ES
01625 523945
(Tel. & Fax)
Mon,- Fri 8.30am – 6.30pm
Sat 9.00am-1.00pm
TESCO IN-STORE PHARMACY
Kiln Croft Lane
Handforth SK9 3HL
0161 2517347
(Tel. & Fax)
Mon-Sat 9.00am-9.00pm
Sunday 10.00am-4.00pm
HOLMES CHAPEL
LLOYDS PHARMACY
39-41 London Road
Holmes Chapel CW4 7AP
01477 532347 (Tel.)
01477 535517 (Fax)
Mon-Fri 8.30am-7.00pm
Sat 8.30am-5.00pm
KNUTSFORD MANNINGS CHEMIST
38 Princess Street
Knutsford WA16 6BN
01565 633078
(Tel. & Fax)
Mon-Fri 9.00am-7.00pm
Sat 9.00am-5.30pm
Boots
64 King Street
Knutsford WA16 6DT
01565 633114 (Tel)
01565 631350 (Fax)
Mon – Sat 9.00am – 5.30pm
Sun 11.00am – 4.00pm
MACCLESFIELD
ASSURA PHARMACY
Waters Green Medical Centre
Sunderland Street
Macclesfield SK11 6JL
01625 664405 (Tel.)
01625 619984 (Fax)
Mon-Sat 7.00am-10.00pm
Sun `` 10.00am – 8.00pm
LLOYDS PHARMACY
46-48 Charlotte Street
Macclesfield SK11 6JB
01625 424895
(Tel. & Fax)
Mon-Sat 8..00am-10.30pm
Sun 9.30am-10.30pm
THE WESTON PHARMACY
5-6 Weston Square
01625 423465 (Tel.)
Mon,Tues,Thur,Fri
9.00am-6.00pm
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Earlsway
Macclesfield SK11 8SS
01625 613836 (Fax) Wed, Sat 9.00am-5.30pm
Tesco In Store Pharmacy
Hibel Road Macclesfield SK10 2AB
01625 603449 (Tel and Fax)
Mon – Sat 8.00am – 8.00pm
Sunday 10.00am – 4.00pm
Sainsbury’s Pharmacy
61 Cumberland Street
Macclesfield
SK10 1BJ
01625603906 (tel-fax Mon - 8:00 am – 11:00 pm
Tues – Fri 7:00 am – 11:00 pm
Sat 7 00 am – 10:00 pm
Sun 10:00 am – 4:00 pm
MIDDLEWICH ROWLANDS PHARMACY
24 Lewin Street
Middlewich CW10 9AS
01606 837604
(Tel. & Fax)
Mon ,Tue, Thur, Fri
09.00am – 13.00pm & 13.20pm – 18.00pm
Wed
09.00am – 13.00pm & 13.20pm – 17.30pm
Sat
09.00am – 13.00pm & 13.20pm – 16.30pm
NANTWICH CO-OP PHARMACY
Church View Primary Care Centre
Beam Street Nantwich CW5 5NX
Tel : 01270 627565
Fax : 01270 624176
Mon – Fri
08.00am – 18.30pm
SAINSBURY’S IN-STORE PHARMACY
Middlewich Road
Nantwich CW5 6PH
01270 618591 (Tel.)
01270 618591 (Fax)
Mon-Fri 7.00am-11.00pm
Sat 7.00am-10.00pm
Sun 10.00am-4.00pm
NORTHWICH DAVENPORT CARMICHAEL LTD
76 Runcorn Road
Barnton CW8 4EY
01606 74671 (Tel.)
01606 782400 (Fax)
Mon-Fri 9.00am-6.00pm
Sat 9.00am-1.00pm
ROWLANDS PHARMACY 01606 74261 Mon – Fri
09.00am – 13.00pm &
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299 Chester Road
Hartford
Northwich CW8 1QL
(Tel. & Fax) 13.20pm – 18.00pm
Sat 09.00am – 13.00pm
TESCO IN-STORE PHARMACY
Manchester Road
Northwich CW9 5LY
01606 311449
(Tel. & Fax)
Mon-Sat 8.00am-8.00pm
Sun 10.00am-4.00pm
Sainsburys Supermarkets Ltd
Venables Road
Northwich
CW9 5RT
01606 314509 Mon & Sat 700AM-10.00PM
Tue –Fri 7.00am-11pm
Sun 10.00am – 4.00pm
POYNTON ROWLANDS PHARMACY
67 Park Lane
Poynton SK12 1RD
01625 873955 (Tel.)
01625 850734 (Fax)
Mon – Fri 09.00am – 13.00pm & 13.20pm – 18.30pm
Sat 09.00am – 13.00pm & 13.20pm – 17.30pm
PRESTBURY D K WOOD LTD
The Village Pharmacy
Unicorn House
Prestbury SK10 4DG
01625 829216
(Tel. & Fax)
Mon,Tues,Wed,Fri
9.00am-5.30pm
Thur 9.00am-6.00pm
Sat 9.00am – 13.00pm
SANDBACH CO-OP HEALTHCARE Ltd
Ashfields Primary Care Centre
Middlewich Road Sandbach
01270 762205 (Tel.)
01270 750372 (Fax)
Mon-Fri 8.30am – 19.00pm
WILMSLOW Boots UK Ltd
Within Waitrose Store
5 Church Street
Wilmslow SK9 1AY
01625 530876
(Tel. & Fax)
Mon-Thur 9.00am- 20.00pm
Fri 09.00am – 21.00pm
Sat 9.00am- 20.00pm
Sun 10.00am-4.00pm
WINSFORD
ASDA IN-STORE PHARMACY
Dene Drive
Winsford CW7 1BD
01606 596410 (Tel.)
01606 596411 (Fax)
Mon 08.00am – 23.00pm
Tue – Fri 07.00am – 23.00pm
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Sat 07.00am – 22.00pm
Sun 10.00am – 16.00pm
CO-OPERATIVE CHEMIST
Winsford Health Centre
Dene Drive Winsford CW7 1AT
01606 592543
(Tel. & Fax)
Mon-Fri 8.30am-6.30pm
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APPENDIX 3
Emergency Palliative Care Medicines Support Service Date Expired Stock Claim Form
Service Provider
Address
Expired stock
Drug Form Quantity Purchase cost Purchased from
Claims will be paid within 28 days of submission of this form accompanied by a purchase invoice. Send completed claims form to:
CCG Geographical location of Pharmacy service provider
Invoice details
NHS Vale Royal CCG
Northwich Winsford (and surrounding areas)
NHS Vale Royal Clinical Commissioning Group 02D Payables K955 Phoenix House Topcliffe Lane Wakefield
WF3 1WE
NHS South Cheshire CCG
Alsager Crewe Haslington Middlewich Nantwich Sandbach (and surrounding areas)
NHS South Cheshire Clinical Commissioning Group 01R Payables K945 Phoenix House Topcliffe Lane Wakefield WF3 1WE
NHS Eastern Cheshire CCG
Alderley Edge Bollington Congleton Disley Handforth Holmes Chapel Knutsford Macclesfield Poynton Wilmslow (and surrounding areas)
NHS Eastern Cheshire Clinical Commissioning Group 01C Payables K935 Phoenix House Topcliffe Lane Wakefield WF3 1WE
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Appendix 4.
Think Pharmacy Urgent Palliative Care Medicines Service Declaration and Self Assessment Monitoring Document: 2014-17
Community pharmacies providing an Urgent Palliative Care Medicines Service will be reimbursed at £200 per year, irrespective of the volume of items / prescriptions dispensed. The fee will be paid as a lump sum on receipt of an annual self assessment service monitoring declaration and declaration of intent to provide the service from the named community pharmacy for the proceeding 12 month period.
1. Service Monitoring, self assessment declaration
The pharmacy has the following procedures/processes in place (Please circle as
appropriate)
A standard operating procedure (SOP) or guidance which specifically details the overall delivery of this service. Y N
Completed and documented review of the SOP/guidance annually. Y N
Trained all staff to follow the service delivery specification. Y N
A training log that details training given to staff. Y N
A process in place that ensures that all new staff are aware that this service is proved by the pharmacy and continuity of service is maintained during and after staff changes. Y N
A copy of the latest service specification, in the pharmacy for reference. Y N
Summarise any issues the pharmacy has encountered with the delivery of the service
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2. Provision of Service, Declaration of intent
I confirm that the named pharmacy will continuously provide an Urgent Palliative Care Service in accordance with the Service Specification for the period 2014-2015
I confirm that by agreeing to provide the Service this form acts as an Invoice for payment.
Pharmacy
Full address
Signed
Date
Position
Please complete the Self Declaration and submit this form for payment. Claims will be paid within 28 days of submission of this form accompanied by a purchase invoice. Send completed claims form to:
CCG Geographical location of Pharmacy service provider
Invoice details
NHS Vale Royal CCG
Northwich Winsford (and surrounding areas)
NHS Vale Royal Clinical Commissioning Group 02D Payables K955 Phoenix House Topcliffe Lane Wakefield
WF3 1WE
NHS South Cheshire CCG
Alsager Crewe Haslington Middlewich
NHS South Cheshire Clinical Commissioning Group 01R Payables K945 Phoenix House
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Nantwich Sandbach (and surrounding areas)
Topcliffe Lane Wakefield WF3 1WE
NHS Eastern Cheshire CCG
Alderley Edge Bollington Congleton Disley Handforth Holmes Chapel Knutsford Macclesfield Poynton Wilmslow (and surrounding areas)
NHS Eastern Cheshire Clinical Commissioning Group 01C Payables K935 Phoenix House Topcliffe Lane Wakefield WF3 1WE
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