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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

This service scored 59 (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. At the time of the assessment 1 person was receiving care and support from the service. Any safety events were recorded and learning from the events was discussed with the staff team during meetings. At the time of our assessment, no safeguarding events had been raised and from reviewing the accident logs, the registered manager was aware of the need to analyse themes and trends if further safety events occurred.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. During the last assessment, the person’s care plan and risk assessment did not contain sufficient information to ensure information with professionals was up to date or reflected the individual’s needs. However, during this assessment, there was more important information recorded which would ensure effective transitions between services for the person. The service worked closely with the person’s GP and district nursing service, highlighting concerns to them where necessary.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. At the time of the assessment, there had been no events which required a statutory notification, or involvement with the local authority and the registered manager understood their responsibility to report safety events. Staff were knowledgeable around keeping people safe from harm and had received the relevant training for their role. Improvements had been made since the last assessment around the application and understanding of consent principles within the Mental Capacity Act 2005. The service had input from the local authority to assess the person’s capacity and the relevant information was documented within their care plan. At the time of this assessment, the service had implemented new policies. However, the policies for safeguarding and the mental capacity act required further personalisation to guide staff in their behaviour, decision making and practice. The mental capacity act policy referenced legislation, which was not applicable for this region, so we could not be assured that staff had the correct service information around the application of the mental capacity act to inform their practice. These findings were fed-back to the registered manager who acknowledged the policies were a current work in progress and formed part of their governance improvement plan.

The provider did not always work well with people to understand and manage risks. During this assessment, we saw improvements in the detail and information within the person’s care records, which enabled staff to deliver care in a safer manner. However, we fed back to the registered manager that some areas of risk for the person still required assessing, such as an environmental risk assessment and more detail to be added to the person’s fire risk assessment so staff are equipped with the knowledge on how to support the person in an emergency. The service had recently implemented a new care system which would allow the management and oversight of risk to improve. However, this required embedding into practice to ensure a robust process was in place for the person receiving care, and for future people joining the service. At the time of this assessment, we could not be assured that the oversight of risk was effective, due to new systems being in place which had not yet been routinely tested.

The provider did not always detect and control potential risks in the care environment. Although appropriate falls and equipment risk assessments were in place for the individual and staff had received training in health and safety and knew how to assess and report environmental risks. For the person receiving care, we found there was no environmental risk assessment in place, which would provide staff with knowledge about any potential risks within the person’s home, or any environmental risks to the person. This did not reflect the requirements within the service’s policy and as a result, we could not be assured the assessment of the person’s environmental safety had been considered.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. During our last assessment, the service was in breach of regulation relating to safe and effective staffing. We found previous records relating to recruitment did not evidence robust recruitment processes were in place. However, during this assessment, the processes of safely recruiting staff had improved. At the time of this assessment, the service had 3 staff members carrying out care duties, including the registered manager. When reviewing the staff files, there was now a clear process in place to assess and gather information about a staff member which, was in line with our regulations. For 1 new staff member, there were gaps in employment history. This was fed back to the registered manager, who advised they would address this. The service’s new recruitment process was deemed effective. Whilst we acknowledge this, further time was required to ensure new recruitment systems and processes were fully embedded and improvements sustained for future applicants.

The provider did not always assess or manage the risk of infection. Staff had all received training in infection prevention and control (IPC) and no concerns were raised by staff about the availability of personal protective equipment (PPE). However, the service’s IPC policy discussed areas which had not been implemented into practice, such as an IPC risk assessment for the person and the requirement that the Infection control lead would complete a monthly audit of IPC risks posed to the person and for staff. Therefore, we could not be assured that the current system in place was effective in assessing and monitoring the risk of infection within the person’s home.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff received training in medicines administration, and their competency was assessed. The staff member we spoke with told us how they would safely respond to any medicine errors. An appropriate medicines risk assessment was now in place for the person receiving care and support, this addressed the person’s ability to take their medicines and how staff should support them with this task. However, we found conflicting information within the person’s medication assessments around allergies, which the registered manager said they would address with the person’s GP.