Hales Group Limited - Waveney

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed autistic people and people with a learning disability respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. At the time of the assessment, the service was supporting 1 person with a learning disability. As they were not receiving the regulated activity of personal care, we did not review their care records, however, the registered manager demonstrated they had regard to ‘Right support, right care, right culture’, and was able to describe how this guidance was implemented in line with people’s care needs.

There were systems in place to assess risks to people and ways to reduce them, but the quality of risk assessments varied, with some risks being very well detailed whilst others were not. Records did not always describe people’s needs and how staff would support them. This was important as there were new staff working at the service who required accurate guidance to enable them to provide care which was effective and safe. The registered manager who started in post in September 2025, had already identified the need for improvement in risk assessments. Additional digital tasks were added to the information seen by staff on a daily basis so they understood the risk to people. This included risks such as diabetes, falls, choking, and skin integrity. This action reduced the risk of harm whilst risk assessments were being updated.

Safeguarding concerns about people using the service were reported to the local authority safeguarding team, however, the provider had not always submitted statutory notifications to CQC as required. People told us they always received their visits by care staff, but some experienced a delay in care staff arrival times. Some people felt the newer staff needed additional training, and better consistency of staff visiting them so they could build trust. The registered manager was monitoring this weekly to try and improve people’s experience. Governance systems were in place which identified where improvements were needed. This included audits of medicines records, care records and the quality of documentation. Improvements were made as a result of the audits being undertaken, for example, the quality of recording in medicines records and daily notes. Where improvements had been identified, additional training was implemented, such as record keeping workshops and medicines refresher training.

People were supported to stay healthy and to access external healthcare services.

During and following the inspection, the registered manager and regional manager took action to begin rectifying areas which required improvement.