Waxham House

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.

This is the first assessment for this service since registration under the new provider. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to people’s safe care and treatment, safeguarding and staffing.
 

This service scored 44 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Managers lacked understanding as to what met the threshold of a reportable event, which meant the provider was not promoting a culture of continuous learning and improvement by routinely sharing lessons learnt with staff. Managers failed to demonstrate they had embedded effective processes to identify, monitor and promote learning from events at the service.

Processes for reviewing and learning from incidents were not clear, consistent or effective. They failed to ensure managers shared identified learning from events with staff to improve outcomes for people. Managers’ audits of adverse events, including falls and accidents, were not robust or effective. For example, where people had experienced several falls, the processes in place did not include managers reviewing mitigating factors or identifying possible patterns, themes and trends to reduce reoccurrence.
 

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The provider did not have robust systems to share essential information between services when people received support elsewhere. Sharing information helps ensure risk mitigation and continuity of care in a person-centred way. However, information shared did not always contain up to date, accurate, or sufficient detail, such as the need for medicines to manage specific conditions. This placed people at increased risk of not having their assessed needs met.
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

The provider’s processes and systems for safeguarding people did not effectively protect people from neglect, abuse and improper treatment.

Leaders failed to act consistently and ensure people were protected from the risk of harm and abuse. They did not always ensure people were appropriately protected from the risk of avoidable harm. During the assessment, we raised 2 safeguarding referrals to the local authority team. For example, we observed a person who was unable to mobilise independently being unsafely supported using moving and handling equipment; we raised this immediately with the management team. We then observed staff using the same unsafe practice with the person for a second time. The provider had failed to review and update the person’s risk assessment to reflect clear guidance with sufficient detail for staff how to support the person safely.
The provider failed to consistently identify indicators of abuse or poor care. Where concerns were identified, the provider did not always respond without delay to mitigate potential risks to people’s safety. For example, we identified a risk related to people’s sexual safety which the leadership team had not recognised. Following our feedback, the provider took action to improve oversight and people’s safety.

The provider failed to investigate incidents or accidents and act to ensure people’s safety. Managers did not check safeguarding records to ensure actions following a safeguarding incident were complete, correct and timely. For example, records relating to accidents and incidents from January 2025 to March 2026 showed 85 unwitnessed falls, 15 witnessed falls and 1 controlled fall. Logs had not been completed detailing what action had been taken and the outcome to help minimise further incidents, this was confirmed by the manager. The provider’s training matrix showed not all staff had received falls prevention training. Out of 18 care staff 12 had not received training and 6 were not up to date. This meant the provider could not be assured staff had the skills to help prevent people’s falls.

The provider failed to ensure people were deprived of their liberty in line with legal requirements. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found 3 people were being deprived of their liberty and the provider had failed to make the required application made to the authorising body.
 

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.

Individual safety risks were not comprehensively assessed, understood or monitored. Where action was taken to address risks, plans were not clear or co-ordinated. Care records for people who had health conditions such as Parkinson's disease, diabetes and heart conditions were not sufficiently detailed to ensure staff had the information required to care for people safely and effectively. For example, where a person had a diagnosis of Parkinson’s disease and was prescribed medicines for symptom control, there was no risk assessment in place to support and guide staff around the importance of time sensitive medicines. The care plan was very limited; there was no information about symptoms and progression of the condition. Staff confirmed they did not have training relating to Parkinson’s disease.

Safety risks in relation to diabetes and heart conditions were not comprehensively assessed, understood or monitored and care plans lacked important information about the conditions. Guidance did not contain sufficient information to enable staff to effectively monitor diabetes. Risk management plans we reviewed for 2 people who had a diagnosis of diabetes contained copied and pasted information, which was not individualised to reflect how each person’s condition affected them. This included a lack of detail around how staff should monitor blood sugar levels, when and the target ranges for the safe management of diabetes.

A person who was prescribed medicine for a heart related condition did not have a care plan or risk assessment in place. This meant staff could not access guidance they needed to be aware of, such as signs and symptoms and when to seek urgent medical help in the event of deterioration.

There was no effective monitoring in place for people who were at risk of constipation. For example, there were no bowel monitoring records in place for people whose care records indicated the risk of constipation and who were prescribed medicine to help alleviate this condition. Constipation if undetected can impact people’s health and wellbeing. The provider could not be assured they were managing the risk of constipation through effective monitoring and administering medicines in line with people’s needs.
 

The provider did not always detect and control potential risks in the care environment.

The provider failed to effectively assess or manage environmental risks, including the risk of legionella. There were no robust systems or management oversight in place to ensure water safety at the service. For example, monitoring checks gave no assurances that water temperatures were within the safe ranges, and there was no regular flushing of little used outlets. There was no legionella risk assessment in place to ensure staff knew what their legal requirements were and how to manage the risks. The provider did not have effective oversight where these tasks were delegated, and management told us staff completing these checks had not received training.

The provider did not effectively assess or manage environmental and equipment-related risks in relation to hot surfaces and bed rails. Areas of the service had exposed hot pipes and electric heaters in use with no protective covers; there were no risk assessments for this. Some bedrails were in use without safety bumpers, and some bumpers were not full length; this meant people were at risk of entrapment. Bedrails risk assessments were generic and contained the same information, which had been duplicated from person to person.

The provider failed to effectively assess and manage the risk of fire. For example, the provider had failed to act in line with their fire risk assessment from 2024. It identified a fire door in poor condition with a timescale of 1 month to rectify. This door remained in the same poor condition almost 2 years later. Additionally, the provider had failed to act and make all changes in line with assessments undertaken by the fire service in September 2025 and February 2026. We therefore shared our findings with the fire service.

At the time of our assessment not all windows had restrictors in place to prevent falls from height. The provider had failed to assess this risk. The provider failed to secure all large pieces of furniture, such as wardrobes, to prevent them tipping. Additionally, the provider had failed to assess this risk. However, since our visits, the provider has provided evidence that these are now in place.
 

Leaders 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.

The provider could not be assured staff had the essential skills and knowledge required to deliver care safely and effectively. The providers training matrix showed staff had not been supported to access training relevant to the people they supported including in relation to Parkinson’s disease, diabetes and catheter care. The training matrix identified that all staff did not have training in safeguarding children, learning disabilities mental health.

The provider could not always be sure staffing levels were sufficient to meet people’s needs as they were not using a systematic approach to determine staffing levels. Staff told us there were not always enough staff and they did not have enough time to spend time with people.
The provider failed to undertake recruitment checks in line with regulatory requirements. For example, there were gaps in staff employment histories, and a lack of pre-employment checks regarding satisfactory evidence of conduct in previous care employment.
 

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.

Systems in place were effective in maintaining a clean environment and managing risks of infection. Designated cleaning staff were employed, and we observed areas of the home were clean and smelt fresh.

Staff were observed using personal protective equipment (PPE) such as gloves and aprons, appropriately.

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 provider could not be assured medicines were consistently administered safely in line with legislation and guidance. We reviewed the records for 2 people who were prescribed a transdermal patch. The body maps did not show patches were rotated between sites on the body in line with the manufacturer’s guidance. A lack of rotation could lead to an increase in adverse reactions, potential overdose of a medicine or allergic contact dermatitis.

The provider could not be assured people received time-sensitive medicines as prescribed. For example, a person with Parkinson’s disease was prescribed medicines to be administered at specific times. These were normally within 30 minutes of the person’s individually prescribed administration time to ensure their symptoms were kept under control. However, staff had only initialled the MAR when they gave this medicine and did not record the exact time given.

Protocols to support the administration of PRN medicines (medicines taken when required) were not always in place. Where they were, they lacked detail and did not reflect people’s individual needs. This meant staff would not always know when a PRN medicine should be administered, and how to do so safely. When PRN medicines were administered, staff did not always record why or if the medicine was effective. This information is useful when monitoring how effective medicines are and, for example, deciding if a review might be needed by the GP. These included medicines prescribed for people’s heart conditions, respiratory conditions and anxiety.

Staff did not always understand their roles and responsibilities in relation to medicines management. Not all staff who administered medicines were sufficiently trained or had been assessed as competent to undertake medicines administration tasks. Staff competency assessments in relation to medicines were limited on what was being assessed. For example, the competency assessments did not include administration of medicines requiring additional controls, eye drops, or application of patches.

Medicines were not consistently stored safely in line with legislation and guidance. For example, we found a medicines storage area unlocked and accessible to unauthorised individuals. We reported our concerns to the management team. However, we again observed unauthorised individuals had access to medicines as keys were left unattended in a communal area.