Hales Group Limited - Waveney

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• 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 service. This key question has been rated 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. The registered manager had only been in post since September 2025, and in that time had been working towards an improved and supportive team culture. Staff told us that in the past year, they had not always felt supported or valued, but the culture within the service was improving. One staff member told us, “[Registered manager’s] leadership style and the way they relate to staff is excellent. They take the welfare of carers seriously and ensure that any concerns raised are addressed, which is one of the best qualities a manager can have. Because of this, many carers are happy and satisfied, and this is clearly reflecting in the smooth running of the branch.” Another told us, “Things are getting better for sure. [Registered manager] really cares and [quality manager] is so approachable. They really care about all the clients.” Relatives felt the overall management was better, but several told us that communication could be improved. The registered manager told us, “I am working on gaining back people’s trust.” They intended to make contact with people and relatives on a more frequent basis to improve communication.

The provider had inclusive leaders at all levels who understood the context in which they delivered care. Prior to the inspection, the registered manager, regional manager and quality officer had identified where improvements were needed and had an action plan in place covering the relevant areas. Leaders were open about issues identified within the service and were responsive to feedback received both during and following our assessment and took immediate steps to action areas and improve safety. Staff had confidence in the management team to improve the quality of people’s care, and support staff in their roles. One staff member said, “I have spoken to several carers, and the feedback about [registered manager] has been consistently positive. I would not be surprised if they scored over 100% in any staff survey.” A social care professional said, “I am confident [registered manager] will address things and get people onboard with improvements.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.Staff were aware of the procedures for whistle-blowing and understood their role and responsibilities of reporting concerns and knew who to go to if they needed to. Whistle-blowing is the act of reporting wrongdoing, misconduct, or illegal activities within an organisation.One staff member said, “If I saw [concerns] with a member of my team, I would report this to my branch manager and I would write fully detailed visit notes and email a statement of events to my branch email address.”Another said, “I know if I raised concerns I would be listened to.”Comments from staff in the most recent survey showed mostly positive responses to a range of questions. This helped the management team to gauge staff views and experiences in their roles.

The provider valued diversity in their workforce. Systems were in place for flexible working arrangements. Staff did not have any concerns with lack of support and were positive about the service and the management team who they felt was making Hales a better place to work. There was evidence of staff meetings and supervisions to show staff were included in updates and feedback. Staff were confident to raise any concerns and ideas that could support the service. One staff member said, “Personally I think the service itself is well led, compliant and well informed. I think that staff sickness could be improved but this is something that the branch cannot control as such for when staff are unwell.” Another said, “Many [staff] may not say it directly, but they truly appreciate [registered managers] efforts.”

Although the provider had clear responsibilities, roles, systems of accountability and good governance in place, we found they had not submitted 2 reportable incidents to CQC via a statutory notification. They acknowledged the oversight and subsequently submitted these to CQC. They had also amended their governance to ensure these were not missed in the future. Following the inspection the registered manager had submitted new notifications for other reportable incidents, demonstrating that new systems in place were working effectively.

A box of staff recruitment files were found unsecured in an unlocked room which staff had access to. These files held potentially sensitive and confidential information. When we brought this to the attention of the management team, they ensured they were removed and locked away.

There were multiple audits and quality checks in place to identify where improvements were needed, and these were used to good effect. For example, audits in relation to medicines documentation showed that month on month staff recording was improving. Audits of care plans identified issues with daily notes, and training was arranged. There was an action plan in place which included areas for improvement and who was responsible for each action. Some audits needed slight amendments to aid clarity of information. The registered manager was receptive to this feedback. 

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 provider worked with the local authority, other health professionals, care staff, people and relatives to gather their views about the service and share learning and suggestions to improve the service.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. The provider welcomed ideas and suggestions for improvement and service development. They intended to arrange training for staff in a specialised age simulation suit designed to allow staff to experience the physical impairments associated with ageing. This offers the opportunity for staff to experience the impairments older people can experience, and understand better how much this can impact people in their daily life. The management team also welcomed external training from the local authority such as record keeping training.