Polly Care Services Ltd

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• 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 newly registered 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 risk management.

This service scored 62 (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. Lessons were learnt to continually identify and embed good practice.

Lessons were learnt to continually identify and embed good practice. The registered manager understood their role under the Duty of Candour. They told us, “Through our surveys and meetings, we have listened and apologised and we have given everyone a chance to state what they think, where there should be improvements, and we have taken this back so we can make improvements.”

The registered manager had processes for dealing with incidents, accidents and complaints. They investigated these and developed plans for improvements. These were shared with staff. The staff confirmed that the registered manager discussed adverse events with them so they could learn from each other. Relatives we spoke with told us they were well informed when things went wrong, and they were confident improvements were made as a result.

The provider had a learning culture which was adopted by all staff. When things happened, discussions and meetings were held to explore what had occurred. Effective changes in the provider’s systems were put in place to make improvements.

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.

The provider carried out thorough assessments of people’s needs, consulting with the person, their representatives and other professionals involved in their care. The registered manager told us they liaised regularly with the local authority, district nurses and GPs and had a positive working relationship with them. The director added, “It is good. We work well with [healthcare professionals]. We have some clients where we are their main point of contact to communicate with the GPs or district nurses.”

The service had up to date policies and processes in place. Staff were required to read, understand and follow these.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They shared concerns quickly and appropriately. The 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.

The provider had processes in place to help safeguard people from the risk of abuse and people told us they felt safe. One person told us, “Oh yes I’m safe, they are all very polite and talk to me.” Relatives agreed and said, “Yes [family member] is safe… They really keep an eye on [them]” and “Oh yes, very safe, [family member] knows them all and they genuinely like each other.”

The provider worked with the local authority and other organisations to help investigate allegations of abuse and to keep people safe.

The provider did not always work well with people to understand and manage risks. Staff did not always have enough information to provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were not always protected from the risk of avoidable harm. Where risks were identified, we saw there were not always robust risk assessments in place. Some people’s care records failed to clearly identify how they would be safely and appropriately supported.

For example, the care plan for one person with diabetes did not include if they had particular nutritional requirements, or any instructions or recommendations for staff to follow in the event of the person becoming unwell due to their condition.

We found for another person with epilepsy, their care plan did not include any information about this condition, and no risk assessment was provided. There were also no instructions for staff to follow in the event the person had a seizure.

A third person’s care plan indicated they were, ‘at risk of injury if [their] wheelchair slides on slopes or if transfers are not managed safely.’ However, there were no details on how to support the person to mobilise safely in order to reduce this risk. Furthermore, the ‘Mobility requirements’ section of the care plan was blank.

In the mobility section of a fourth person’s care plan, it stated, ‘The care worker needs to push [Person] on [their] hoist and move [them] around to places [they go].’ This was confusing because it may indicate that the person was transported while in a hoist.

For the same person, in the ‘Details of support required’, it stated the person was not able to stand. However, there were no details on what level of support they required to stand. In addition, the care plan stated the person was unable to move on and off the bed, but there was no detail on how to support them with this.

Although systems were in place to review care plans and ensure they were sufficiently detailed, containing key information and guidance for staff, these had not identified the lack of key information in some people’s care plans.

We fed this back to the registered manager, who told us, “For clarity, all critical information has always been visible to carers through the Access Care Planning app when they are allocated to a client. To make this even more accessible, we have now placed the same details into the care plans themselves.”

Although they provided us with the updated care plans, there were still some significant shortfalls and a lack of important information in these.

There were processes in place to help ensure that risks to people were assessed and mitigated effectively. The registered manager reviewed each incident or accident to establish the cause and what actions were needed to reduce the risk of re-occurrence.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The management team ensured they carried out a full assessment of people’s living environment to help ensure this was safe and if any adaptation was necessary. Where risks were identified, the registered manager took appropriate action, which included liaising with the relevant professionals and relatives. The registered manager told us, “At the initial assessment, we examine the environment. If we identify a risk, we discuss this with the person. It can be a trip hazard, and some changes may have to be made.”

Staff knew to report any concerns in relation to the safety of the environment so appropriate action could be taken.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development.

Most people confirmed the staff worked together to provide safe care that met their individual needs. However, some people and relatives told us they did not always get their visits at the agreed time. Their comments included, “Timings! We have only just started with these literally and we are not impressed! We asked for them to come at 9am as I had a hospital appointment for 10am and they came at 9.30am…My next appointment was for 11am so I asked for a carer at 10am and no one came at all… I rang the office and they didn’t explain anything. They didn’t understand or didn’t care” and “[Care worker] has not been wonderful and the timings are poor.” We fed this back to the registered manager who provided evidence of their actions to make improvements.

Although most people had regular care workers, some people reported they did not always have regular staff, and this meant they did not always supported to build a rapport with them. Their comments included, “We rarely get the same person, we don’t want different people. We want continuity” and “I used to get the same carer but now it’s 6 or 7.”

We raised this with the registered manager, who told us, “We recognise that changes of carers can be unsettling, though sometimes they are necessary to ensure timely service delivery. Carer changes may be required due to emergencies, ensuring adequate days off, or supporting non-driving carers by pairing them with drivers to help them achieve their required weekly working hours. We consistently reassure clients that we aim to keep a stable team of up to four carers per client to minimise disruptions while still managing operational demands.”

The provider carried out checks on the suitability of staff before they started working at the service. However, we found some staff only had character references on file, and these had not been signed or dated. This meant the provider could not be sure these were genuine, and there was a risk that people could be supported by unsuitable staff. We discussed this with the registered manager, who acknowledged this concern and told us, “To address this, we have now introduced a digital reference request form to strengthen our recruitment and compliance process. This records the full name and email address of the referee, captures for whom the reference is provided, includes the date and time stamp of submission, notifies the office once completed, and identifies whether the reference is employment-related or character-based. In addition, we have started retrospectively reviewing existing staff to ensure all staff members have at least one work reference on file.”

Other systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom and Disclosure and Barring Service (DBS) checks. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

People and relatives, we spoke with said they were happy with the care workers who provided care and felt they were well trained. Staff received enough training to meet the needs of people they supported. We saw evidence the staff were subject to regular spot checks of practice, supervision and had their competencies assessed to help ensure they were providing good, effective care to people who used the service.

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. The staff received training in infection control and followed safe guidelines.

People told us they felt safe from the risk of infection and cross-contamination. They told us the staff followed safe infection control practices and wore their personal protective equipment (PPE) appropriately. The senior staff carried out regular spot checks to ensure this was the case.

The provider ensured that the staff had access to PPE whenever they needed it. The registered manager told us, “PPE is picked up from the office location and sometimes delivered to a person’s house. We audit this to check if we have enough.”

The staff received training in infection prevention and control. A staff member told us, “I’ve had infection control training that covered things like hand hygiene, using PPE properly, recognising signs of infection, and following the correct procedures for cleaning, waste disposal and reporting any concerns. I help prevent the spread of infections by washing my hands and keeping good hygiene, as well as wearing PPE when needed, and disposing of it immediately after use. I make sure areas and surfaces are clean and I dispose of the waste safely.”

The provider did not always make sure that medicines and treatments were managed safely and met people’s needs, capacities and preferences.

Although people did not express any concerns about receiving their prescribed medicines, we identified some concerns related to the medicines records and auditing system.

The provider used an electronic system to manage medicines. This enabled the care workers to sign for medicines administration on their handsets. The management team were able to check that medicines had been administered in real time. However, some staff were still using paper-based medicines administration records (MARs) or were using both systems. We reviewed the electronic MARs for individuals receiving support with their medications and identified several gaps in recording administration for September, October, and November 2025. The registered manager told us this meant the member of staff had signed on the paper MARs.

The registered manager and director told us they collected all the paper MARs at the end of each month so they could carry out their monthly audits. We requested to see these so we could cross reference and ensure the identified gaps had been signed on the paper MARS. The director was unable to find these and admitted they had not been collected. This meant we could not be sure people had received their medicines appropriately and as prescribed. Furthermore, this indicated the provider had not carried out checks of the MARs, and the shortfalls had not been investigated. This is discussed further in the well-led section of this report.

We discussed the concerns with the registered manager, who told us, “We acknowledge the concern regarding missed medication entries. Medication itself was not missed; however, documentation was not always recorded in a timely manner.” They also added that they had now transitioned fully to the electronic system to avoid further confusion.

The senior staff undertook regular checks and observations of staff during medicines administration to help ensure this was done safely and in accordance with the person’s care plan.

Staff received training in the administration of medicines and had their competencies assessed to ensure they maintained their skills and knowledge. A member of staff told us. “My competence is assessed by a senior member of staff to make sure I’m following the correct procedure. I also have regular refresher training to keep me up to date.”