Hales Group Limited - Leeds

On this page

• 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.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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.

The provider demonstrated a positive learning culture, with effective systems in place to record, review and learn from incidents. Incidents were analysed to identify contributing factors and inform actions to reduce the risk of recurrence. Following a fall involving a person who was not wearing their falls pendant, risks and support arrangements were reviewed to improve safety while respecting the person's right to decline its use. Staff were encouraged to revisit this discussion regularly to support informed decision-making and ongoing risk management. Staff understood the providers incident reporting processes and described an open and transparent culture where concerns could be raised confidently.

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 had effective systems in place to ensure people received safe, coordinated care. Staff worked collaboratively with health and social care professionals to support positive outcomes. Risks were identified, assessed and managed proactively. Safety was prioritised through thorough assessments, appropriate referrals and ongoing monitoring of risk management processes. Care and support were planned with people, their representatives and relevant professionals to promote continuity of care and ensure smooth, well-managed transitions between services.

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

Management and staff demonstrated a clear understanding of how to identify and raise safeguarding concerns. All staff had completed safeguarding training and described well-established communication and escalation processes to ensure concerns were reported promptly. Records reviewed during the assessment supported this. One staff member told us, “If I do have a safeguarding concern, I have been instructed to inform the office, so I would do this.”

However, we identified that not all safeguarding incidents had been notified to CQC in line with statutory requirements. There was no evidence this had affected the provider’s management of safeguarding concerns, which had been appropriately addressed, investigated, and followed up. The provider assured us that future notifiable incidents would be reported promptly and that retrospective notifications would be submitted where required, with actions taken to mitigate risk and promote people’s safety.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were in place and up to date. People were involved in reviewing and managing their care.

Staff understood their responsibilities to keep people safe and told us how they involved people in their care. Staff received clear, up to date information about people’s risks and any safeguarding needs.

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

People were supported to keep their environment safe. The provider took appropriate steps to identify, assess and manage risks within and around people’s homes. They included vital information such as, if people had pets and what to do in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staff were recruited safely, with all required pre-employment checks completed before employment commenced. New staff received a structured induction and ongoing training to ensure they had the knowledge, skills, and confidence to perform their roles effectively.

Staff told us they received regular supervision and support and felt encouraged in their role. One member of staff said, “They are supportive. Nothing really changes for me as it’s mainly to check I’m doing everything right; they are always supportive.”

All staff we spoke with told us there were sufficient staffing levels to meet people’s needs. They said that any concerns regarding staffing could be raised with management and would be addressed promptly.

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.

People told us staff supported them in ways that promoted good infection prevention and control. Staff received training in infection control and were familiar with the provider’s infection control policies. They had access to appropriate personal protective equipment and used it correctly to reduce the spread of infection.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

The system for managing medicines was electronic, and records of medicines administration were well maintained, showing that people were generally supported to take their medicines safely. However, the quality of information recorded was variable and in some areas required improvement. The system for confirming people’s current prescribed medicines needed to be strengthened, and PRN protocols lacked guidance to support safe administration. Some people received time-sensitive medicines at the correct time, but this was not consistent for everyone. Records about the ordering, disposal and storage of medicines were also inconsistent. There were clear records identifying who was responsible for administering medicines. Staff were trained in medicines administration and assessed as competent to administer medicines safely. A strong auditing process was in place, with regular monitoring of medicines management. Where concerns were identified, actions were taken and learning was shared with staff.

Immediately following the inspection, actions were taken to improve medicines management and safety. The provider also developed an action plan to address all the concerns identified. Although it was too early to assess whether these actions had been effective, we were assured that the immediate concerns were being addressed appropriately.