Updated 2 January 2025
Date of Assessment: 27 January 2025 to 5 February 2025. The service is a residential care home providing support to older people and younger adults, including those living with dementia, physical disabilities and/or sensory impairments. The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. This inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of falls risk. This inspection examined those risks. The provider was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were not found at this assessment, and the provider remained in breach of this regulation. The provider was in breach of the legal regulation relating to premises and equipment, and good governance. Learning was not always identified when people had accidents, incidents or falls. Leaders did not always complete a robust analysis of accidents, incidents or falls to identify themes or mitigate risk. People’s care plans and risk assessments had not always been reviewed following safety incidents, and some had not been reviewed in 5 months despite people experiencing falls. Safety concerns were identified within the environment, which included hot water exceeding recommended temperatures, access to boiling water taps, use of portable heaters, a window restrictor not being in place and some trip hazards. The provider responded immediately and took action to rectify environmental concerns. The providers governance systems had not always picked up on risk or areas for improvement. During our site visit we observed some areas in need of further cleaning, however overall, the service was clean. Staff followed best practice guidance regarding infection, prevention and control.