Motaryli Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment, consent and safe staff recruitment processes.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Although the service had 1 person receiving support at the time of inspection, a safeguarding and accident monitoring log was in place, with evidence of reviewing and actioning any concerns raised and sharing findings within team meetings.

The provider did not always manage or monitor people’s safety. The person’s care plan and risk assessments did not always accurately reflect their needs or provide sufficient guidance to staff to allow them to support this person safely. Staff knew this person well which mitigated some risk of harm. Although, the care records would not be effective in highlighting the person’s care needs if shared with other professionals. However, we did find the service had a good relationship with the persons GP and informed medical professionals of important changes in the person’s care. We saw evidence of highlighting skin integrity concerns with the district nurse and requesting the person’s medicines be adjusted due to the person displaying increased pain levels.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. We found there was a lack of understanding around the Mental Capacity Act 2005 and ensuring the principles were reflected in practice. There was no documented information in the person’s care plan regarding their capacity, despite the service managing the persons finances informally. However, the provider shared safety concerns quickly and appropriately. The staff member we spoke with had received safeguarding training and had knowledge on protecting individuals from abuse and taking appropriate action. The staff member told us, “I would first document in detail the signs of abuse that I have would have observed. It is also important that I report my concerns to my manager, and if the individual is in serious harm, I would notify the relevant authorities.” The registered manager understood their responsibility to report any safeguarding concerns to the local authority and to CQC. At the time of the inspection there had been no events which required a statutory notification.

The provider did not work well with people to understand and manage risks.Although the service only had 1 person at the time of the inspection, we found this person’s care plan and risk assessments did not always contain sufficient information to guide staff on managing and mitigating risk. More detail was required around this person’s risk of falls, continence, skin care, equipment and ability to mobilise safely. At the time of the inspection, we found the risk of harm to this person was reduced, as staff knew this person’s needs well and were knowledgeable about the potential risks. However, we discussed with the registered manager, the potential future risks if care plans and risk assessments were not thorough, and new staff were being introduced into the service. The registered manager provided assurances of their plans to update this person’s care plan and risk assessments to ensure the person’s needs were reflected fully, and this information was reviewed on a regular basis.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The fire risk assessment did not contain sufficient information on how to ensure the persons safety during an emergency. The current fire risk assessment spoke about the risk of overloading plug sockets, but no information on how staff were to monitor this daily. There was no reference to working fire alarms, if the person was able to contact emergency services due to their hearing impairment, or any reference to the adaptations in place to ensure safety such as a personal alarm pendent or modified fire alarms. The registered manager told us the fire service had recently attended to address risks. However, this information could be placed within the risk assessment to reflect risk management and ensure staff were aware of how to mitigate or manage risk for this person. The registered manager assured us they would update the risk assessments to ensure environmental safety was appropriately assessed.

The provider made sure there were enough qualified, skilled and experienced staff, whoreceived effective support, supervision and development. Staff told us they felt supported in their role and had completed an induction programme before they were able to work independently. However, for the 2 members of staff employed at the service, records relating to recruitment did not demonstrate robust recruitment checks and process were in place. We found gaps in staff employment history, dates of previous employment not visible and the references provided did not identify who had provided them and were not in line with the provider’s policy, which stated 2 references were required. The registered manager assured us; these recruitment files would be rectified with the correct information in place.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had access to enough personal protective equipment (PPE) to allow them to carry out their role safely. The registered manager told us, “There is always sufficient supplies of PPE available for the staff to use.” Staff at the service had received Infection prevention and control (IPC) training and knew how to implement this training within their role.

The provider made sure that medicines and treatments were safe and met people’s needs,capacities and preferences. Medicines were administered to the person safely and audits were in place to ensure any medication errors were dealt with promptly. The staff member we spoke with had received medicines training and told us how they would safely respond to any medicine errors. However, staff were leaving medicines out for the person to take independently and there was conflicting information in the care plan as to the person’s ability to complete this task independently and safely. There was also no appropriate risk assessment in place for this task. We spoke with the registered manager who agreed to take action to address this.