Polly Care Services Ltd

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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

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

The people we spoke with knew who the registered manager was and were generally positive about them. One person told us, “Management? Very good” and another said, “Definitely recommend. They do a good job and keep me informed and keep in contact. They pass on information and tell each other which gives good continuity.”

The management team told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. A care worker told us there was a good and positive culture within the service where people and staff had a good rapport, and the atmosphere was one of respect and care.

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions. The registered manager told us, “We would like to grow bigger but step by step. Sometimes, we learn from inspections. I think although we would like to expand, we want to learn along the way first. The staff have to be happy, and we have to be able to deal with things as they happen.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Overall, people and relatives were positive about the registered manager and the senior staff team. A relative told us, “They are like an extended family now. I’m going to have them myself. Can’t get a better recommendation than that.”

The staff reported they felt supported by the management team, who were visible and helpful when staff needed them.

The registered manager was an experienced leader who strived to make continuous improvements for the benefit of people who used the service. They held a degree in health and social care. They told us, “I have been interested in care work for some time. I started as a care worker and have developed from there.” The director had also achieved a qualification in social care management before going into nursing.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People were given information when they started using the service about how to raise a concern and said they knew how to make a complaint. There were regular meetings to enable people and staff to speak up and report any concerns.

Staff knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home. A care worker told us, “Whistleblowing is exposing bad practice at work. I have never had to do this and I believe I would contact the manager to report any issues as well as contacting external bodies.”

The provider had processes in place to support staff to speak up. This included supervision meetings, staff meetings and a whistleblowing policy. A care worker told us, “Team meetings are held monthly and I’m always in attendance. Yes, they are useful as they help with providing organisation wide updates as well as any client updates and structural changes.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The managers treated their staff equitably and supported them to meet their individual needs. The registered manager told us they valued the staff and wanted to make them feel appreciated.

The provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. The registered manager told us, “When we have interviews, we ask questions around their needs, and how we can meet their needs such as childcare. There is a form that they fill out. We consider their background such as their religion.” The director added, “We encourage staff to let us know if they need some days off. We give them opportunities such as earlier shifts to meet childcare needs.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had processes to monitor the quality of the service, but these had not always been effective because they had failed to identify the concerns we found during our inspection. The provider’s monitoring systems had failed to identify and take appropriate action in relation to repeated missed staff signatures on the electronic MARs. The registered manager confirmed they were responsible for checking electronic records. They told us, “I mainly look over things. The field office does the paper-based audits, MAR charts and the care logs. I do the electronic ones. Which include care plans and risk assessments.”

Despite telling us the paper MAR charts were collected at the end of each month to be audited, these had not been collected for the last 3 months. Therefore, no audits of these had been undertaken. This also meant the provider had not cross referenced the signature gaps on the electronic MARs with the paper-based ones. Therefore, the provider could not be sure people had received their medicines as prescribed.

Although the provider said there were regular audits of care plans to ensure information was recorded and guidance was provided for staff, some of the care plans we reviewed lacked information and detail, and some sections had been left blank. Where some risks had been identified, for example, the risk of falls, there was contradictory information about how to manage this, and a lack of guidelines and information on how to minimise risk for the person. The provider took action to improve the information in care plans and sent us updated care plans. However, there were still several shortfalls that had not been addressed.

The provider’s monitoring systems had also failed to identify that recruitment checks were not always robust, as some files contained only character references and these had not been signed or dated.

Although the staff received training, we saw that some of the training was overdue.

The registered manager was receptive to our feedback and put measures in place to make the necessary improvements, such as making their recruitment processes more robust and instructing staff to only use the electronic system going forward.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager told us they worked with healthcare professionals so people’s needs would be met and had a good working relationship with them. They told us, “We tend to meet with healthcare professionals like the occupational therapists and the social workers in reviews for clients.”

The provider had systems and processes to ensure people’s needs were reviewed regularly. The registered manager told us they ensured the staff learned from healthcare professionals involved in people’s care to help them better understand people’s needs.

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 the development of safe and effective practices and research.

Overall, people and relatives were happy with the care they received and praised the service. One relative told us, “The carers are mostly very nice people. They are polite and well mannered. They are very friendly and chat to me as well.”

People told us they were consulted individually during a review or regular conversation to find out if they had any concerns or requests. We saw that people’s opinions and requests were taken seriously.

The provider took our feedback seriously and provided us with a clear action plan following the inspection. The registered manager told us they had already visited people to discuss concerns and had met with the care and office staff to ensure improvements were made without delay.