moderate“Staff recorded administration of these medicines as 'medipack' and did not list the individual medicines administered at each dose.”
moderate“There was no audit of the medicines listed in the medication profile of the care plan to ensure that an accurate record was kept of the medicines administered by care staff.”
consent capacity
1 finding
moderate“Decision specific MCA assessments and best interest decisions had not been completed for some people who lacked capacity.”
care planning
1 finding
moderate“Risk assessments required further development as they were not individual to the person. This meant that staff did not always have the written guidance they needed to help people to remain safe.”
record keeping
1 finding
minor“We could not audit the financial transaction record as receipts were disorganised and not kept with the actual record.”
person centred care
1 finding
minor“The care plan for hygiene and dressing for another person was more of a task list...The care plan did not include any evidence of person choice.”