Polesworth Group Pooley Heights

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question as good. At this assessment the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had clear responsibilities, roles, systems of accountability and good governance. They shared information with others securely when appropriate. However, they did not always act on the best information about risk.

The provider had systems and processes in place to check on the safety and quality of the service. Overall, these checks identified where improvements were needed and these were acted on.

However, improvements were needed in the registered manager acting on risk and implementing mitigation whilst investigating incidents. For example, a near miss incident had taken place 5 days prior to our assessment. Whilst we were assured the registered manager had begun their investigation into this; we were not assured risk mitigation had been implemented to prevent potential avoidable harm whilst the investigation was underway. We discussed this with the registered manager, the provider’s chief executive officer (CEO) and an assistant manager during our visit. They agreed lessons could be learned and going forward a risk assessment would be implemented for any similar incidents to reduce the potential of people suffering avoidable harm. Following our visit, a robust risk assessment was shared with us.

The registered manager told us they checked on staff’s skills and competency assessments were completed. We found these were not always effective in ensuring staff followed the training they had been given. For example, the registered manager told us, “I do not think staff always take a medication administration record (MAR) with them when giving medicines to a person in their bedroom or elsewhere in the home.” Where staff did not consistently use a person’s MAR in line with the provider’s policy when administering medicines, this posed risks of medication error. During our assessment, the registered manager took immediate action to direct staff to physically take a person’s MAR with them when administering a person’s medicines in any area of the home.

The registered manager checked staff’s skills on using moving and handling equipment. Whilst we found no evidence of any incidents related to staff using a hoist, the registered manager did not have a qualification higher than those being assessed. We discussed this with them, and they told us the CEO would facilitate them to undertake a ‘train the trainer’ course.

Overall, the registered manager had a good oversight of the home and planned checks were completed. However, improvements were needed in the day-to-day oversight of the home so that issues needing immediate attention were not missed or left until scheduled checks took place. For example, 2 temperature recordings for the medication fridge dated during September 2026, were exceptionally higher than the maximum safe temperature. Staff had not escalated this to the registered manager. At the time of our assessment, no medicines were in the fridge, which meant there was no risk of any medicines having become unsafe to use. However, staff told us the fridge was often in use for people’s medicines. With increased day-to-day oversight of the home, the registered manager would have been able to take immediate action to remind staff about the importance of reporting issues to them and to have taken action to check the fridge was operating within safe limits.

Staff felt very supported by the registered manager. One staff member told us, “The manager checks in with me and has been helpful with my shift pattern. They are supportive and amazing.”

Relatives felt the registered manager was approachable and listened to them.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.