moderate“some records only said, 'Got [person] up' or 'put [person] to bed', with no further information about how the care had been provided.”
moderate“Daily notes, where staff recorded what care had been provided during visits were poorly written, as they did not provide enough detail, and some were illegible.”
governance
1 finding
moderate“The registered manager had not implemented a system for auditing documentation. Consequently, poor record keeping in the daily notes had not been identified.”