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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. At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, the way people’s medicines were managed safely, safeguarding people, maintenance of the premises and equipment.
 

This service scored 28 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.
Staff did not always record accidents and incidents using the correct forms. For example, a person had experienced a fall in January 2026, which had not been recorded on the accident form and therefore did not show on the accident and incident records report.Accidents and incidents had not been effectively monitored and analysed to identify themes, mitigate risks and prevent further occurrences.
Lessons learned were not always documented, and where they were, it was unclear how this information was shared with the staff team.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.
People’s safety was not robustly monitored or managed. Risk assessments were not always adequate, and some risks had not been assessed appropriately, reviewed or mitigated. We found that 1 person had been living at the service for over a month, and they did not have a full care plan in place.
Other people's care plans included some significant discrepancies and were not always updated, creating risks during transitions, for example several people’s care plans did not clearly identify their choking risk and that they required a texture modified diet. This meant information passed to other agencies such as hospital staff did not contain accurate information.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.
We found incidents of concern were not consistently recorded or identified using the systems in place. This meant safeguarding concerns had not always been investigated, reported to the Local Authority or to the Care Quality Commission (CQC).
The service did not have a safeguarding log in place to monitor and track safeguarding concerns; we could not be assured that incidents of concern were not always identified and reported to the Local Authority, as required.
We found that not all people who use the service had Mental Capacity Assessments, best interest forms completed or Deprivation of Liberty Safeguards (Dols) in place or applied for.
People told us they felt safe, and relatives said staff were kind, but governance failures placed people at risk of harm.
 

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
The provider failed to do all that was reasonably practicable to keep people safe from avoidable harm. Staff did not have the guidance necessary to provide safe care for people living at the service. People did not have specific risk assessments to identify individual risks in relation to their health conditions and care needs. This meant measures were not in place to minimise risks. We found concerns around individual risk management including wound care, catheter care, and diabetes. For example, we identified 2 people who were insulin dependent diabetics, neither had diabetic risk assessments or care plans in place which recorded this or had an individual blood glucose range. Another 2 people were identified to be at risk of choking and risk assessments to mitigate their risk of choking had not been completed.
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.
We found internal and external environmental audits had not been completed since October 2025. Hot water outlet temperatures had not been checked since December 2025 which increased people’s risk of scalds and burns.
The service did not have a system in place to check mobility equipment was safe for use between Lifting Operations and Lifting Equipment Regulations (LOLER) inspections, furthermore we found hoist and stand aid slings had not been LOLER inspected. LOLER ensures lifting equipment is safe for use and properly maintained.
We found numerous concerns related to fire safety processes. Personal Emergency Evacuation Plans (PEEPs) were not printed and readily available, and 5 people did not have a PEEPS in place. The service did not have an emergency grab bag in place. A fire risk assessment had been completed in 2022 and had not been reviewed or updated and staff had not completed a fire drill since March 2023. This meant people were at ongoing risk of significant harm in case of an emergency evacuation.
We raised these concerns with the provider on the day, and PEEPS were then completed and printed. We raised our concerns with the Norfolk Fire and Rescue service.
 

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.
From observation and viewing rotas, it appeared appropriate staffing levels were in place; however , staff were observed taking their break at the same time which then left no staff available to support people if needed. This was also raised by a relative who said, “My relative asked if [they] could go to the toilet, staff asked if [family member] could wait until after they had had their break.” We received mixed feedback from relatives on staffing levels. A relative told us, “They do struggle they do need more staff,” while another said, “I think there are plenty of staff.”
Staff did not have the training and skills required to ensure people received safe and good quality care and support.
Care staff had not completed all necessary training needed to safely meet people’s needs, for example dysphagia, catheter care, blood glucose monitoring and end of life care, despite providing care and support to people with these significant needs. There were no staff working during the night that were able to monitor people’s blood glucose levels.
We found several staff had overdue training required, a staff member’s safeguarding adults training being recorded as overdue since 2022.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.
Infection control measures were not fully effective. We found an infection control audit had not been completed since October 2025. Cleaning schedules were not place; the service used a cleaning diary which was completed with where had been cleaned that day. This was poorly maintained, and there were gaps where no cleaning had taken place. On the 4 February 2026, the laundry room was observed to have a build-up of dirt and dust, with dirty mops on the floor and a dirty hand-washing sink. These concerns had not been identified by the service, once raised to the provider they took action to rectify this.
We observed some areas that had stained walls and skirting boards; however, people’s bedrooms and communal lounges were observed to be clean.
 

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.
We found people’s care plans did not include information on the medicines they were prescribed, how they preferred to take their medicines or guidance on how to safely administer medicines. For example, a person was receiving their medicines covertly, such as hidden in food, this was not recorded in their care plan.
We observed medication administration record (MAR) charts where medicines had not been signed as received and some medicine stock had not been included from the previous month, this included controlled drugs. We were not assured medicines were audited effectively.
We found that ‘when required’ (PRN) medicine charts were not always in place and transdermal patch body charts were not being completed. This was a risk of medicines being given inappropriately.
Staff who were administering medicines were overdue receiving a competency check, not following the provider’s medicine policy. Staff were administering insulin when they had not been assessed as competent to do so by a competent health professional.
The governance systems in place did not identify these concerns.