critical“PRN had been recorded as administered on two occasions but only initialled on one of those occasions with a recording of 'G' for the second occasion.”
record keeping
1 finding
critical“Accurate and complete records were not maintained to ensure care workers had sufficient information to act in people's best interest. Breach of Regulation 17 (2) (b) (c).”
care planning
1 finding
moderate“One core assessment was last reviewed in November 2013 and another in September 2014. Information in people's care files was not always up to date or consistent.”
consent capacity
1 finding
moderate“Best interest assessments...the information was not always completed with enough information to ensure staff understood why the decision had been made.”
governance
1 finding
moderate“Despite the quality assurance checks in place...management of medicines and care planning were being audited but we had concerns about these areas of practice.”
incident learning
1 finding
minor“The recording form provided limited opportunity to learn from these types of incidents and to reduce re-occurrence.”