the process of change and not consistent in providing safe care, while staff failing to visit patients as planned was a "daily occurrence".

image caption The Norfolk and Suffolk NHS Foundation Trust is based at Hellesdon Hospital in Norwich

High staff turnover, vacancies, staff away on courses and sickness all contributed to the high case load, the CQC said.

Staff at the Ipswich home treatment team told the inspectors they had an "unmanageable" caseload of 50, which resulted in care that was "variable and at times poor".

The inspectors said patients were seen face-to-face within the four-hour target and the trust had added extra support and resources.

The trust was told the service required improvement.

The quality of its record keeping was criticised, and inspectors found out-of-date risk assessments and not all patients hadCongenital cholesteatoma isolated to the mastoid presenting as stricture of the external auditory canal.
Congenital cholesteatoma may originate at various sites in the temporal bone. Congenital cholesteatoma of the mastoid origin shows a variable clinical presentation, although the least common site is the mastoid process. We report an extremely rare case of congenital cholesteatoma isolated to the mastoid presenting as stricture of the external auditory canal. A 10-year-old boy presented with stricture of the left-sided external auditory canal caused by bulging of the posterior wall of the external auditory canal. Computed tomography showed destruction of the posterior wall of the external auditory canal by a lesion of soft tissue density in the left mastoid cells. At surgery, cholesteatoma was observed in the mastoid cavity. Although destruction of the posterior