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The Care Trust, a small domiciliary agency providing end of life care to 11 people, was rated Good overall at its first inspection but Requires Improvement for well-led due to ineffective governance and audit systems that failed to identify gaps in risk assessments, incident logging, ECM oversight and CQC notifications. People received safe, kind, person-centred end of life care with strong partnership working, and the provider was receptive to feedback and made immediate improvements during the inspection.