Last updated 23 August 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection was brought forward due to the notification of an incident in which a person using the service sustained a serious injury. The information shared with CQC about the incident indicated potential concerns about the management of risk of falls. This inspection examined those risks.

This inspection took place on 9 May 2018 and was unannounced. The inspection was carried out by three inspectors, an inspection manager, a specialist occupational therapy advisor and two experts by experience. An expert by experience is someone who has experience of using or caring for someone who uses this type of service. .

Before the inspection we reviewed the evidence we had about the service. This included any notifications of significant events, such as serious injuries or safeguarding referrals. Notifications are information about important events which the provider is required to send us by law. We did not ask the provider to return a provider information return (PIR) as this inspection was brought forward from its originally scheduled date. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection we spoke with 12 people who lived at the home and two relatives. We spoke with the registered manager and nine staff, including the deputy manager, care, activities, housekeeping and catering staff. We observed the care people received, their mealtime experience and the interactions they had with staff.

We checked the care records of five people, including their assessments, care plans and risk assessments. We looked at how falls were managed and assessed whether any equipment used in people’s care was appropriate for their needs. We checked the management of medicines. We looked at five staff recruitment files and records related to staff support and training. We checked meeting minutes, the complaints file and reviewed the provider’s policies and procedures.

After the inspection the registered manager sent us further information, including quality monitoring reports, minutes of clinical governance meetings and the home’s emergency recovery plan.