critical“staff had started giving a person their 'as required' [PRN] medicine twice a day. The registered manager told us this was at the GP request. However, the GP had not changed the prescription”
critical“PRN protocols were not always in place or did not contain the necessary information staff required to ensure people received PRN medicines as prescribed.”
care planning
2 findings
critical“Care plans did not always contain sufficient information about people's health conditions. We found no information recorded when people had a diagnosis of epilepsy or multiple sclerosis.”
moderate“staff told us care plans were not always kept up to date. One staff member told us, 'We have been asking them to change and update [person's] care plan as it does not contain the correct tasks'”
staff training
2 findings
moderate“All our training is online. I haven't had practical face to face training in manual handling or basic life support/first aid training.”
critical“AM-R-AZ LLP is registered to provide care to people with a learning disability and who are autistic; however, not all staff had received training in learning disabilities.”
governance
2 findings
critical“Systems and processes in place to audit medicine records were not effective in identifying the concerns we found on inspection regarding incorrect and missing information.”
moderate“People, relatives and staff told us they were not asked for feedback on the service. One person said, 'I have never been asked.'”
staff competency
1 finding
moderate“Agency staff don't know me. They can't always use the hoist and they don't always have the experience.”
supervision appraisal
1 finding
moderate“Staff told us they did not have any 1:1 time to discuss concerns or issues.”
safeguarding
1 finding
critical“The registered manager told us of issues they were having with district nurses requesting staff completed tasks they were not trained to do. The registered manager had not submitted any safeguarding notifications.”
record keeping
1 finding
moderate“Not all people and relatives had seen their care plan. One relative told us, 'We have been asking for a copy of the care plan for ages, we still have not seen it.'”
consent capacity
1 finding
moderate“When the provider completed mental capacity assessments and assessed a person lacked the capacity to make a specific decision a best interest decision had not always been recorded.”
person centred care
1 finding
moderate“during these observations an additional member of staff watched other staff give personal care to people. This was not in line with least restrictive options or maintaining people's dignity.”
incident learning
1 finding
minor“Staff were not offered regular staff meetings to discuss any concerns, improvements or lessons learnt.”