minor“we found the process for disseminating information on lessons learnt could be further developed. We have made a recommendation for implementation of formal systems”
medication management
1 finding
critical“we were not able to find information about the medicines, a medicines risk assessment and medicines administration record sheet (MARs) in the person's care folder.”
care planning
1 finding
critical“we saw in one care plan that there was a different name recorded. It was therefore not clear who this care plan was for.”
record keeping
1 finding
moderate“Care records at times contained conflicting information and didn't reflect the assessed needs of people who used the service.”
governance
1 finding
critical“the quality audit system had failed to identify the issues we found in respect of medicines management and risk management and person-centred care planning.”
person centred care
1 finding
moderate“Care plans viewed were found to be not always personalised and did not always reflect the person's needs and preferences.”