Burrow Down Residential Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment, we rated this key question good. At this assessment, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding, the need for consent, person-centred care, dignity, and good governance.

This service scored 33 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had systems and processes in place to ensure people’s needs were assessed before support was offered. However, we found judgements made following pre-admission assessments were not always followed, and the service did not consistently assess and review people’s health, care, and wellbeing needs in a way that ensured safe and personalised care.

For example, the registered manager told us one person had been admitted to the service following a pre-admission assessment where it had been determined Burrow Down Residential Home was not a suitable placement for them in terms of their compatibility with other people living there, the environment, and staff skills.

Risk assessments for key areas of need, including epilepsy, dysphagia and behaviours that may present risks, were delayed or incomplete. For example, an assessment completed in November 2024 identified several significant risks; however, care records showed the associated risk assessments and staff guidance were not implemented until November 2025. During this period, staff were supporting the person without the necessary information to provide safe and appropriate care. This placed the individual, staff, and others at an increased risk of avoidable harm due to the lack of timely risk management and guidance.

Care records lacked detail about goals and aspirations, and some plans were outdated or missing essential information. Staff told us they often relied on “word of mouth” guidance from other staff and managers, rather than documented plans. This contributed to a breach of regulation relating to safe care and treatment, person-centred care, and good governance.

Relatives told us they were not routinely involved in care planning reviews, and staff confirmed they did not always receive updates when care plans changed. One relative said, “We are not invited to care planning or annual reviews.”

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Care and treatment were not always delivered in line with best practice or supported by evidence‑based guidance. We identified a poor culture within the service that did not reflect best practice for supporting people with a learning disability and autistic people. This limited people’s choices, experiences and expectations. For example, while staff demonstrated a caring attitude, they did not have the required understanding or skills to meet one person’s assessed needs, which had a significant impact on the person’s quality of life.

Furthermore, none of the staff we spoke with were able to describe the principles underpinning the Right support, right care, right culture guidance. Senior staff had not recognised or taken action to address the culture within the service, nor had they ensured staff understood how promoting choice, control, independence and inclusion was essential to improving people’s quality of life. This lack of values‑based practice and leadership oversight increased the risk of people receiving care that was not person‑centred or aligned with best practice guidance.

Systems were in place to help ensure care was delivered in line with best practice guidance. For example, nationally recognised risk assessments were used to assess risks, such as the Malnutrition Universal Screening Tool (MUST) and Water Low Risk Assessment. However, we identified inconsistent application of clinical guidance. For example, staff were unclear about blood sugar escalation thresholds, and records showed missed escalations for abnormal readings. Dysphagia risk assessments lacked specific dietary instructions, and staff could not be sure fortified fluids were offered as required. Pressure care guidance was incomplete, and mattress settings were incorrect for people’s weights.

Staff had received training to ensure they were informed about and kept up to date with best practice guidance. However, we found training did not always determine practice, as detailed within the safe, effective and well-led sections of this report. This contributed to a breach of regulations relating to safe care and treatment, person-centred care, dignity and good governance.

People were happy with the food provided by the service. One person said, "The food is very good!” Another said, “My favourite meal here is Shepherd’s Pie.”

A relative said, “The big thing since he has been there is his diabetes management, which is awesome. He has gone from 18 stone to 10 stone.”

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

The provider had systems and processes in place to support the effective sharing of information with external professionals, including local hospitals, GP practices, primary care services and, where appropriate, relatives. For example, records showed the service worked with healthcare professionals to share important information, and hospital passports were in place to support consistent communication during hospital admissions. Daily handover meetings helped to ensure all staff were kept up to date with changes to people’s support needs.

However, while staff worked hard to support people, teamwork and communication within the service were inconsistent, and systems did not always ensure the safe coordination of care. We found examples where staff failed to seek advice, request support, or appropriately escalate concerns. Although staff had access to people’s care and support plans, we identified records were not always up to date. In addition, some agency staff had not read these plans and were unaware of key health conditions and risks relating to the people they were supporting. This created a risk of people receiving care that was unsafe or not aligned with their assessed needs. This contributed to a breach of regulation relating to safe care and treatment, person-centred care, and good governance.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or, where possible, reduce their future needs for care and support.

People were supported to access a range of healthcare services, including GPs, dentists, opticians, and community-based activities, and to maintain relationships important to them. We saw examples of positive engagement, such as trips to local attractions and attendance at skills centres. However, some people’s health needs were not proactively managed. For example, weight‑management plans were not consistently followed, and referrals to health professionals were delayed or lacked documented outcomes. Additionally, people’s care records contained limited information about how they were supported to make choices, exercise their rights, or develop greater independence.

Relatives had confidence in the staff and told us their loved ones were supported to manage their care, support and health needs by staff who knew them well. One relative said, “I have never been told there is a problem. I asked about some worrying moles, but they said everything is fine. I know she has been to the dentist – whoever helped her at that end did well, and they got her to the doctor.” Another said, “[Person’s name] had an annual health check. Just had reviews this year for dentist and eyes –I took him to the dentist, and he was sedated in the hospital for a complete check-up.”

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Systems to monitor and improve outcomes were ineffective, and quality assurance processes did not identify significant risks. The provider had systems in place to ensure people’s care and support was continuously monitored and reviewed to promote good outcomes for people. Some support plans were informative and provided staff with detailed information on people’s likes, dislikes, personal preferences, care needs, and medical history. However, some lacked detail of the support people needed to meet their assessed needs, develop life skills, and increase their independence, which meant staff did not always have the information they needed to meet people’s needs safely.

Care reviews did not consistently consider all available information. For example, information recorded following incidents was not used to update support plans or inform staff practice. This represented a missed opportunity to identify and address poor practice.

Support plans were not accessible to people, and there was limited information to show how people were involved in developing their care and support. More work was needed to ensure people were truly involved and seen as partners in their care.

Care plan audits were incomplete or missing, and governance systems failed to highlight issues such as unsafe medicine storage, environmental hazards, and gaps in risk assessments. This contributed to breaches of regulations relating to person-centred care, safe care and treatment and good governance.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack the mental capacity to make particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

The provider had policies and procedures in place to support people in understanding their rights. Records showed, and staff confirmed, that training had been provided in safeguarding adults, the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). The registered manager and staff spoke about the importance of obtaining consent and applying the principles of the MCA.

However, this knowledge was not consistently applied in practice. For example, the registered manager told us they had submitted DoLS applications for people living at the service because they would not be allowed to leave without staff support due to safety concerns. Despite this, staff had not completed MCA assessments or best interests’ decisions to determine whether these restrictions were lawful or the least restrictive option. In addition, these restrictions were not referenced within people’s support plans or risk assessments. This meant restrictive practices were being applied without an appropriate legal framework or clear justification, placing people at risk of having their rights restricted unlawfully.

Care records for 2 people indicated staff used door alarms and audio monitors to monitor their movements. Staff confirmed people did not have the capacity to understand these restrictions or give informed consent. The registered manager confirmed people’s capacity to consent to accept these restrictions had not been formally assessed. Neither had a decision been made to apply these restrictions in people’s best interests, in line with the principles of the Mental Capacity Act 2005.

The failure to assess and record people's capacity and best interest decisions risked compromising people's rights. This contributed to a breach of regulation relating to the need for consent, safeguarding, person-centred care and good governance.

Following the assessment, the registered manager told us that one person was able to provide informed consent to the use of the monitor, and they had updated the person’s support plan accordingly.