moderate“records were not always detailed about how risks were managed. For example, information was missing from repositioning guidance, medicines administration records (MARs)”
medication management
1 finding
moderate“not all people's medicines administration records (MARs) were complete or accurate. Where people were supported with medicines that were over the counter, staff had not followed the provider's policy”
governance
1 finding
moderate“not all quality audit and monitoring processes were effective in identifying and enabling improvements. For example, not documenting best interests decisions, not always providing enough detail in care plans”
consent capacity
1 finding
moderate“Where people had restrictions on their liberty there was no best interest decision records to guide staff on how to manage risk in the least restrictive way.”
care planning
1 finding
minor“in one care plan it stated 'needs Include help in eating meals' but not how this was to be achieved. Also, some wording in care plans, such as can become aggressive, lacked detail”