Updated 30 January 2025
We visited the service on 5 February 2025.
The inspection was prompted, in part, by notification of an incident following which a person using the service had died. The incident did not meet the threshold for a criminal investigation. However, the information shared with CQC about the incident indicated potential concerns about the quality of care plans. This inspection examined those risks. The service is a care home providing care for up to 30 people. At the time of the inspection, there were 30 people using the service. We found medication was not always managed safely, care plans did not always include key information about risks to people, some care plans were missing or had minimal information about people’s assessed needs and fire risks were not always managed safely. Although staff had received safeguarding training, some staff were unable to tell us basic information on how to safeguard people from abuse or neglect. Whilst audits and checks were being completed, we found these did not always identify and resolve the issues we observed whilst on inspection. We found the care provided by staff was high quality, person centred and staff knew people well. People and their family were involved in the assessment of their care needs. Care plans and risk assessments were reviewed. Leaders and staff had a shared vision to provide high quality care. Leaders were present and visible in the service and there was enough staff to provide safe care. We found the provider was in breach of legal regulation relating to managing risks to people, ensuring people had a robust care plan in place and having systems in place to monitor the quality of the service.