Hales Group Limited - Waveney

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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 service. This key question has been rated Requires Improvement. This meant some aspects of the service were not always safe and 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. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Quarterly reports were completed which highlighted key lessons learned and the preventive actions being applied to minimise future risk. The January 2026 report included documentation accuracy, safeguarding, medication safety, missed visits, and concerns raised directly by CQC. Required actions were listed to improve the identified areas. The registered manager understood their responsibilities under duty of candour and shared information with the relevant stakeholders.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The provider worked with a number of professionals to help ensure continuity of care within the service and made appropriate referrals to healthcare professionals. One professional told us, “I have found [registered manager] to be very responsive and proactive. Communication has not been an issue, and they are always happy to joint visit if there are issues to discuss.” Staff said they would report any incidents or issues to the registered manager, record in the daily notes, inform the family (where appropriate) and take any necessary action should someone require medical attention. One staff member told us, “If I notice any changes in a person such as being [unwell] I would assess the situation to see if they require emergency help, if it is something that their GP needs to be aware of I would contact them or if it was something that falls under the district nurses care I would get in contact with them. Full visit notes would be completed and marked as important as well as phoning my office branch. Family would be informed as to what was going on and what my concerns are.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service reported concerns of abuse to the local authority safeguarding team as required to ensure people were protected and received the support they needed. However, the submission of statutory notifications to the Care Quality Commission (CQC) had not always been made in accordance with legal responsibilities. The registered manager has now submitted these and amended governance processes to ensure oversight is more robust in the future.

Staff received training in safeguarding adults and children and the Mental Capacity Act 2005 (MCA). People’s records could be further improved to ensure people’s ability to make decisions about their life, care and treatment in line with the MCA was clearly documented. Staff told us they would always act on any concerns of abuse. One staff member told us, “[If there were concerns of abuse] I would document this fully in my visit notes. If there was immediate danger to my client, I would phone the relevant authorities and I would make sure my office was aware.”

The provider did not always work well with people to understand and manage risks. Risk assessments held on people’s care records varied in quality and some were not always sufficiently detailed. This related to risks such as falls, skin integrity, diabetes, and moving and handling. However, the registered manager had already identified that risk assessments needed work, and an improvement plan was in place which included the need for more robust care records for staff. Actions showed work was in progress and how many records had been completed to date. There were 'digital tasks' on the electronic application which care staff used during their visits to people. Additional digital tasks were added to the existing care plan tasks to ensure that all identified risks were clearly recorded and visible to care staff on every visit. This meant care staff could see any specific risks affecting the person, and how they would support the person to minimise those risks. One staff member told us, “I do have enough information when I visit people, and important things like if someone is a diabetic, awareness of [high and low blood sugar] symptoms are recorded.”

The provider did not always ensure potential risks were fully documented relating to the care environment. Some improvements were needed in the level of detail recorded in people’s care plans in relation to fire escape plans, and the process needed to evacuate individuals from their home. The registered manager was aware and was making the improvements to the recorded information. Other risks relating to the environment were documented and in place prior to staff delivering care and support. This process helped to identify and mitigate potential environmental hazards, promoting the safety and wellbeing of both people using the service and staff.

The provider did not always make sure that staff visiting people’s homes were sufficiently skilled and experienced. Several people told us that they had difficulties with the younger staff who were newly employed. One person said, “There are lots of new carers and some of them are very young with no real-life experience and don’t always do things the way an older person would.” Another told us, “There are lots of different carers some are really youngsters. They are mostly okay, but some could be given extra training.” A relative told us, “The younger carers are nowhere near as good. [Person] is supposed to have a strip wash, but some of them don't even do enough for hands and face.”

There were mixed views from people about the continuity and reliability of the care they received. One person told us, “There are lots of different carers and they will make changes to the carers coming but we find out about these from the carers when they come [to our home] not the office.” A relative told us, “The number of carers can be excessive as [person] struggles with faces they do not recognise. It would be much better with familiar faces, the mornings are the worst.”

Several people raised concerns about late visits, or visits which were too early and which didn’t tie in with their daily routine. One person said, “I have an office number and while they are not dismissive, they just don't know how it feels to have that uncertainty.” A relative told us, “The time keeping isn’t good, and friends told me when they heard I had Hales that timekeeping isn’t good with Hales and this has certainly been the case.” Other people told us they received consistent carers, and reliable visits. One person said, “I have the same 3 carers, they arrive on time and they are absolutely brilliant.”

The registered manager had systems in place, including audits, to improve punctuality and consistency of care within the care staff team. They understood that the mixed feedback indicated that improvements were needed and as such was monitoring these areas on a regular basis.

Staff received training relevant to their role, for example moving and handling and medicines. Where people had specific needs such as support with catheter care, diabetes, and skin integrity, training was provided for these care tasks. Staff told us they received the right training. One staff member told us, “When I started, I received both online and practical training, and I completed shadow shifts. I have had ongoing training sessions, and I have been booked onto refresher training in the coming weeks. I do feel that the training I have had so far has been sufficient.” Another told us, “I feel that I have the relevant training to complete my job effectively and know that if there is something training wise that would be useful, I can speak to my branch manager.” Staff told us they received supervision sessions to discuss their practice and any concerns they had. Staff also received competency checks where they were observed in the community. One staff member said, “Yes we do have supervision sessions, and [staff member] comes out and watches you do the job, checks are made that we are doing it properly.”

Recruitment procedures were in place which included the necessary checks to ensure staff were suitable for the role. Audits were undertaken to ensure relevant documents and checks were made prior to new staff starting. However, for 1 staff member the dates of previous employment were not noted to ensure there were no gaps in their employment. The registered manager asked the staff member to provide these following the inspection.

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 told us they had access to personal protective equipment (PPE) such as gloves and aprons.

The provider did not always make sure that medicines were recorded in line with people’s needs and preferences. There were some gaps in the recorded information available to staff to enable them to manage people’s medicines. This related to information about how people have their medicines given to them. The Hales medicines policy stated that medication plans should reflect the person’s goals, routines, triggers, and what matters to them. This also included documenting how the person prefers to be supported during medication administration, including sensory or environmental adjustments. We found the level of detail in people’s care plans varied in relation to this, but the registered manager was aware and was working on improving this area.

Despite this, people told us they received their prescribed medicines safely. Records showed where people refused medicines or needed a review of their medicines, that appropriate clinicians were informed and advice sought. One person told us, “They [care staff] do all my medicines and even pick them up if I need it. They are very good with that side of things.”