Witnesham Nursing Home

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 changed to 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 regulation in relation to people’s safe care and treatment and fit and proper persons employed.

This service scored 50 (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 told us they were working to promote a culture of safety consistently across the service. Opportunities to capture learning and further embed good practice were not always maximised.

Staff described a positive and supportive team culture, reporting that both the registered manager and leaders maintained an open-door and were approachable, visible, and willing to provide guidance when needed. Staff spoke positively about the support they received and felt able to raise concerns, seek advice, and contribute to discussions about the service. We observed this during the daily meeting held at the service.

Despite these strengths, governance and oversight processes were not always effective in promoting continuous learning and service improvement. Review of records identified that accidents, incidents, and significant events were not consistently subjected to robust analysis to identify trends, contributory factors, or recurring themes. The registered manager was aware of this shortfall and was working proactively to make improvements.The provider acknowledged they needed more time to embed changes but were working with their care teams to achieve this and drive improvement.

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.

Staff and managers had established positive links with external organisations and healthcare professionals, which promoted effective information sharing and partnership working. Electronic care records enabled important details about people's needs and preferences to be transferred efficiently when accessing other services. This helped to ensure continuity of care and reduced the risk of information being lost during transitions.

The provider did not always work effectively with people and healthcare partners to ensure people's rights were upheld and protected. Applications for Deprivation of Liberty Safeguards (DoLS) were not always submitted in a timely manner, which meant legal arrangements were not always progressed promptly.

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 Mental Capacity Act (2005) (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found mental capacity assessments and care plans were in place where appropriate. However, records identified significant delays in submitting some DoLS applications, meaning processes had not always been implemented in line with legal requirements. The provider had recently identified these issues, through an external audit, and had started to take action to improve oversight and ensure applications were submitted in a timely manner. The registered manager had begun to take oversight of authorised DoLS, including any associated conditions and renewal dates.

People and their relatives told us they felt safe at x Nursing Home and would raise concerns if they needed to.One relative said, “I feel my [family member] is safe, I have no concerns and the care [family member] gets is very good.” Another relative told us, “My [family member] is absolutely safe… staff are lovely and give us updates. Staff are well trained and competent. “

Staff were knowledgeable about recognising and responding to abuse and described appropriate actions they took to keep people safe. One staff member said, “If I had a safeguarding concern, I would make sure the person was safe immediately, report the concern to the nurse in charge or manager without delay, document the facts accurately, and follow the safeguarding procedure. If I felt the concern was not being acted upon appropriately, I would escalate it to a more senior manager or the relevant safeguarding authority.”

There were opportunities to further strengthen how the provider worked with people to understand and manage risks. This meant care did not always consistently meet people’s needs or promote their safety and well-being.

Some people either had, or were at risk of developing, pressure ulcers and had care plans in place which identified the need for regular repositioning. We found significant gaps in repositioning records for several people. For example, one person's care plan directed staff to reposition them throughout the day and night. However, records contained numerous omissions and did not provide assurance that this support had been delivered consistently in line with assessed needs. Similar concerns were identified for other people who required regular repositioning. The lack of accurate and complete records meant the provider was unable to evidence that appropriate measures had been taken to reduce the risk of pressure damage and promote skin integrity.

These shortfalls increased the risk of avoidable harm. A recent external quality assurance audit had identified many of these concerns, meaning the provider was aware of the issues and areas requiring improvement. Whilst we observed evidence of improvement in risk management, governance and oversight systems had not yet become sufficiently embedded or effective to consistently identify, assess and mitigate risks. The provider acknowledged these areas for improvement, which reflected findings from their independently commissioned review, and was open and transparent in sharing both the review outcomes and their improvement plans. Although action had been taken and progress was evident, further time was required for these improvements to become fully established and consistently effective in practice.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, and facilities supported the delivery of safe care. During the inspection, we found a number of environmental concerns which indicated poor oversight and maintenance of the premises. Some fire doors had been wedged open, creating a potential fire safety risk, and the provider had failed to ensure that the fire risk assessment, due for review in April 2026, had been updated. Records showed fire safety checks such as alarm and emergency lighting tests had taken place; however, there was no evidence that any fire drills had been conducted in 2026. Following our inspection visit the provider located evidence of the fire drills being completed and supplied us with a copy.

The provider had also not ensured robust monitoring arrangements were in place to manage water temperature risks. The registered manager explained that health and safety checks and audits had not consistently taken place resulting in gaps in monitoring and oversight. We found action was being taken to replace all temperature regulating valves, as a number were faulty, to reduce the risk of scalding.

The environment was not consistently maintained to a safe or acceptable standard. Numerous bathrooms, door frames and door sills were dirty and cosmetically damaged, and equipment was excessively rusty, meaning it could not be effectively cleaned.

External environmental risks had also not been effectively managed, as there was a gap in the fencing at the rear of the property through which a person could have fallen, together with damaged webbing between railings. In addition, environmental monitoring systems were not consistently operated, with gaps identified in mattress audit records and a lack of management oversight. These findings demonstrated that equipment, facilities and environmental systems had not always been maintained in a way that supported the delivery of safe care and protected people from avoidable harm

The provider did not always ensure systems and processes relating to the recruitment, assessment and oversight of staff were operated consistently.

People were not protected by safe recruitment practices and safe staffing and recruitment processes required improvement to ensure that only suitably qualified, safe and competent staff were employed. We found gaps in the obtaining and verifying of staff employment histories and securing appropriate references to provide sufficient assurances regarding an applicant's suitability to work with people. In addition, robust checks to confirm staff right to work in the UK before employment commences had not been consistently undertaken.

Disclosure and Barring Service (DBS) checks, were conducted. DBS checks provide information, including details about convictions and cautions held on the Police National Computer. Where a DBS disclosure had identified relevant information, appropriate risk assessments and monitoring arrangements had not consistently been implemented and regularly reviewed. Failure to address these areas increased the risk of unsuitable individuals being recruited, which meant there were risks that the safety and well-being of people using the service were compromised.

There were gaps in staff training and inconsistencies in induction and supervision processes. The registered manager reported that the service was behind on a lot of staff supervisions and appraisals.

This meant the provider could not be assured staff had received the necessary training, support, and oversight to carry out their roles safely and effectively. As a result, there was an increased risk of staff not having the knowledge, skills, or competency required to meet people's needs consistently, potentially impacting the quality and safety of care, reducing accountability, and increasing the likelihood of poor practice going unidentified or unaddressed.

The provider did not always assess and manage risks relating to infection prevention and control. The provider could not demonstrate that equipment was consistently maintained and ready for use when required.

The lack of formal checks and assurance processes increased the risk of equipment not functioning effectively in an emergency and presented potential infection prevention and control concerns where used equipment had not been appropriately cleaned, checked, and monitored. Several surfaces within the service were worn and damaged, which meant they could not be effectively cleaned and decontaminated. This increased the risk of dirt and microorganisms accumulating in these areas and prevented the provider from being assured that appropriate infection prevention and control standards were consistently maintained.

Opportunities were identified to further strengthen how medicines and treatments were managed to ensure they consistently met people’s needs, capacities and preferences.

The provider had not always ensured safe and effective medicines management systems were in place. We found improvements to the safe management of medicines were required.

Medicines stock checks and tally records were not always completed accurately, resulting in discrepancies between recorded and actual stock levels. We also found medicines that had been dispensed for a person but were not clearly labelled or recorded to indicate who they were for, increasing the risk of medicines errors.

Not all people prescribed medicines on an 'as required' (PRN) basis had supporting PRN protocols in place, meaning staff did not always have clear guidance on when these medicines should be administered. Concerns were also raised regarding inconsistent medicines management practices and difficulties embedding improvements. Overall, while some systems and checks were in place, further improvements were needed to ensure medicines were managed safely and records were accurate.

The provider was aware of these concerns through an external audit process completed 10 days previous to our inspection, which had highlighted areas requiring improvement. An action plan had been developed to address the identified issues and strengthen medicines management processes. However, at the time of our assessment, the required improvements had not yet been fully implemented or embedded inpractice. Overall, further action was needed to ensure medicines were managed safely, records were accurate, and governance arrangements were effective in reducing the risk of medicines-related errors.