critical“One person's risk assessment and care plan did not contain important information about the risks associated with their diabetes nor details of who was responsible for administering their insulin”
staff training
1 finding
moderate“Records showed staff had not been trained in managing diabetes. Many staff did not have up to date training on pressure ulcer awareness.”
staff competency
1 finding
moderate“The assessment of their competency in giving medicines was not recorded although we saw this was checked at spot checks of care workers carrying out their duties.”
record keeping
1 finding
moderate“Some files contained details of the person's legal representative when they did not have one. For example, a relative was described as having lasting power of attorney in error.”
governance
1 finding
minor“One staff did not have a reference from their last employer in care and this had not been picked up at interview or when their file was audited. Another worker had an unexplained gap in employment.”
consent capacity
1 finding
moderate“A relative was described as having lasting power of attorney in error...only people with legal authorisation were able to make decisions on behalf of a person.”