moderate“Risk assessments were not clearly documented. Where initial assessments had identified people were at risk guidance was either not in place or limited for staff.”
moderate“One person had needs relating to their diabetes. This was identified in the assessment but there was no guidance in the care plan for staff.”
medication management
1 finding
moderate“Medicines were not consistently recorded in people's medicines administration records. For example, where people were having a topical cream applied this had not been documented as a medicine.”
consent capacity
1 finding
critical
“MCA assessments had been completed but they were not decision specific and there were no documented best interest decisions.”
governance
1 finding
critical“Governance arrangements were not effective in identifying areas of improvement. Audits were not identifying concerns and driving improvements in medicines administration.”
record keeping
1 finding
moderate“There was no care plan audit in place, this meant where care plans were missing or lacked details this had not been identified.”