Burrow Down Residential Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question good. At this assessment, the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to safe care and treatment, safeguarding, person-centred care, dignity, staffing, recruitment and good governance.

This service scored 28 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The registered manager told us there were systems in place to review accidents and incidents to identify themes, trends, and any learning which may help to prevent a recurrence. However, we found systems and processes had not been fully developed or embedded to ensure safety concerns were identified or that learning was shared. The service did not demonstrate a strong culture of learning from safety incidents. While some staff understood the importance of reporting concerns, systems were inconsistent and did not ensure lessons were learned. For example, accident and incident analysis was not routinely carried out; care plans were not updated following incidents, and staff had not received reflective practice sessions or debriefs following incidents. This contributed to a breach of regulations in relation to safe care and treatment, safeguarding and good governance.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Systems to keep people safe were ineffective and placed people at risk of harm. Systems to ensure safe transitions were weak, with limited evidence of pre-admission assessments informing care planning. Risk assessments were not completed in a timely way, leaving people exposed to avoidable harm. For example, a person with a known and documented risk of leaving a service through a window had access to unrestricted windows, despite these known risks. Environmental hazards, such as fire safety checks and water temperature monitoring, were inconsistent. Medicines were stored insecurely, and agency staff were deployed without assurance of their competence. This contributed to a breach of regulation in relation to safe care and treatment, safeguarding, staffing and good governance.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were not protected from the risk of abuse or degrading treatment, and safeguarding systems were ineffective. We identified 8 safeguarding referrals, including concerns about financial abuse and degrading treatment. There was limited evidence to show allegations were identified and investigated promptly. For example, senior managers failed to recognise safeguarding concerns and take action to keep people safe, uphold their human rights or address a poor culture within the service. This led to one person receiving care and treatment that could reasonably be considered degrading.

Some staff lacked basic safeguarding knowledge and could not explain what safeguarding meant. One staff member said, “Safeguarding means closing a person’s curtains.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through the Mental Capacity Act 2005 (MCA) application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

The registered manager and staff had not recognised some people were subject to continuous supervision and control as part of their care and support arrangements and were not free to leave support staff due to safety concerns. The registered manager confirmed people’s capacity to consent to these arrangements had not been assessed, and they had not followed a best interests process, nor had these restrictions been linked to people’s support plans or risk assessments. There was no legal framework in place to support these restrictions.

There was no system or process in place to regularly monitor or review the use of restraint and/or restrictive practices, to ensure they remained the least restrictive option and were lawful.

The failure to ensure staff acted lawfully when depriving service users of their liberties in accordance with The Mental Capacity Act 2005, and to effectively establish systems to investigate and report allegations of abuse, contributed to a breach of regulation in relation to safeguarding, safe care and treatment, the need for consent and good governance.

Some people told us they felt safe and were happy living at Burrow Down. One person said, “Yes, I feel safe, the staff are my friends.” Another said, “Oh yes, I am happy here.”

Some relatives had confidence in the service and staff. One relative said, “[Person’s name] is safe there.” Another said, “[Person’s name] would not be there if I did not feel it was safe.” However, some relatives told us communication with the service was poor. One relative said that staff had informed them of an incident of verbal and physical abuse by a staff member and said they had not received a clear explanation or outcome.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service’s approach to risk management was inconsistent. People were not always protected from the risk of harm, as staff did not always have all the information needed to meet people's needs safely. For example,one person with assessed safety needs in the following areas: nudity, faecal smearing, health and hygiene concerns, medication management, throwing objects, environmental hazards, inability to recognise dangers, and water misuse, had no risk assessments in place for these identified areas of risk for several months following their admission.This placed this person, staff and others at an increased risk of avoidable harm, as staff were supporting them without sufficient information on how to provide safe and appropriate care.

Where risks had been identified, it was unclear what action had or was being taken to mitigate those risks and keep people safe. For example, one person had a known risk relating to the management of their diabetes care. Care records instructed staff to seek medical advice if the person’s blood sugar levels dropped below, or exceeded, a specific range. Care records for October and November 2025 showed blood sugar readings fell outside this specified range on 29 occasions, and staff failed to escalate concerns in accordance with the person’s care plan. This placed that person at risk of rapid health deterioration.

People’s involvement in the development of their care and support varied according to their individual needs and preferences. However, there was limited information to show how staff supported people to be involved in decisions about the development of their care and risk management.

The provider’s failure to ensure they were doing all that was reasonably practicable to ensure risks relating to the safety of people receiving care and treatment were appropriately assessed, mitigated, or effectively managed placed people at an increased risk of avoidable harm. This contributed to a breach of regulation relating to safe care and treatment, person-centred care and good governance.

Some people told us they were happy and liked living at Burrow Down. One person said, "I am happy, yes, thank you." However, people were not aware of their care plans or associated risk assessments. Relatives did not raise any specific concerns about people’s safety. However, they told us they were not always consulted about changes to care plans or risk assessments.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment was not always safe or well-maintained. We found damp and mould in one person’s bedroom, damaged flooring in another person’s wet room, overloaded electrical sockets, and unsecured hazardous substances.

Window restrictors were missing despite known risks. During our tour of the service on 25 November 2025 with the operations manager, we noted windows throughout the first floor had not been fitted with suitably robust, tamper-proof restrictors to ensure compliance with health and safety legislation. This was particularly concerning as one person’s care records identified this as a known risk and stated that window restrictions were in place and monitored monthly. We returned to the service on 27 November 2025 and found no action had been taken to address this serious safety concern. We asked the operations manager to take immediate action to mitigate this risk.

Regular checks of the environment and the maintenance of equipment were not consistently carried out. For example, fire safety checks were overdue; cleaning schedules were not documented, and infection control measures were inconsistent.

Some showers were fitted with thermostatic mixing controls that could be easily overridden, allowing hot water temperatures to exceed 44°C. While each shower displayed a sign stating “Caution: Hot Water,” there was no system or guidance in place to mitigate the risk of scalding. Regular testing arrangements were not in place to prevent water being discharged above 44°C in accordance with the Workplace (Health, Safety and Welfare) Regulations.

Some external doors were not locked and had no device to alert staff if someone left the building unattended. This was concerning because the registered manager told us they had applied for DoLS authorisations to restrict some people’s ability to exit the building without supervision, as some individuals would not be safe if they left without support. This contributed to a breach of regulation relating to safe care and treatment, safeguarding and good governance.

Relatives did not raise any concerns about people’s living environment. One relative said, “It’s well maintained, always painting something in there!” Another said, “The environment is lovely, beautiful environment.”

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

People were not always protected by safe recruitment practices. We reviewed recruitment records for 3 staff members. While some checks had been completed, others were missing. For example, 3 staff files did not contain application forms, references or interview notes, and there were gaps in staff’s employment histories.

The registered manager told us recruitment checks were carried out centrally. The provider was aware some documentation was missing and was taking action to address this. However, there was a lack of urgency to ensure the correct documentation was in place. The failure to establish and operate effective recruitment procedures contributed to a breach of regulation relating to recruitment and good governance.

Other recruitment checks were in place. For example, Disclosure and Barring Service (DBS) checks. DBS checks provide information, including details of convictions and cautions held on the Police National Computer, which helps employers make safer recruitment decisions.

Staffing arrangements were unsafe and did not meet people’s assessed needs, particularly at night. For example, one person who was funded for 2-to-1 staff support did not consistently receive this level of care. The registered manager was unable to provide assurance people were receiving 1-to-1 support in line with their assessed needs. A staff member said, “The biggest issue is staff shortages; this meant some people have missed out on going out, but we have been promised more.”

Agency staff were used frequently, but induction processes were rushed, and competency checks were inadequate. For example, agency staff were deployed without a proper induction or checks on their skills and training. The agency staff we spoke with did not have a basic understanding of the needs of the people they were supporting. The registered manager did not know if agency staff had the right level of training to meet people’s assessed needs.

The registered manager told us all staff completed an induction and did not work unsupervised until they had been assessed as competent. However, there were no records available to confirm inductions had taken place or staff competencies had been formally assessed. Supervision and appraisal systems were poor and were not seen as an opportunity to develop staff’s skills and/or knowledge or challenge poor practice and institutionalised thinking. For example, supervision did not support reflective practice, learning or professional development. Furthermore, none of the staff we spoke with were able to describe the principles underpinning the Right support, right care, right culture guidance. Staff lacked understanding of how promoting choice, control, independence and inclusion is essential to improving people’s quality of life.

We received mixed feedback from staff regarding training and supervision. Some staff were positive about the training provided; others were not. Comments included: Yes, I do feel the training is sufficient and supports us to meet the specific needs of the people here,” and “Yes, the training is good enough.” While one staff member said, “Yes, I have had regular supervision,” others reported the opposite, telling us, “To be fair, I have not had any supervision,” “The last supervision was some time ago,” and “No, I have not had any supervisions since my last probation meeting, which was a year ago.”

The failure to provide enough staff, and to ensure staff had the skills, competency and experience to meet people's assessed needs, contributed to a breach of regulation in relation to staffing, safe care and treatment, person-centred care and good governance.

The provider did not always assess or manage the risk of infection.

Infection control practices were inconsistent and did not fully protect people from risk. Cleaning schedules were unclear, and cleaning records were missing. Although monthly audits were taken place, they did not include any information regarding day‑to‑day cleaning schedules or the cleaning of equipment. As a result, the audits did not demonstrate effective oversight in these areas.Some equipment, such as wheelchairs, were visibly dirty. The COSHH cupboard [Control of Substances Hazardous to Health] was unlocked, and mattresses were stored without clear hygiene protocols. Staff reported PPE was readily available. This contributed to a breach of regulation relating to safe care and treatment and good governance.

Relatives did not raise any concerns about the cleanliness of the service. One relative said, “The home is always spotless.” Another said, “(The) environment is very clean.”

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff did not always involve people in planning.

People’s medicines were not always managed or stored safely. For example, the cabinet used to store people’s medicines was not suitable for its intended purpose and was not secure when locked. A box of medicines, which had not been signed into the service, was stored on top of a filing cabinet, and the keys to the medicine cabinet were kept in an unlocked drawer in the main office. This meant people’s medicines were accessible to unauthorised staff and others.

Covert medicine processes lacked clear documentation, and PRN [medicines to be taken when required] guidance was inconsistent. For example, PRN protocols were in place to guide staff on when to administer these medicines. However, they did not contain sufficient detail to ensure medicines were given consistently and safely.

We noted that after 8 pm, there was not always a trained and competent staff member on duty to administer people’s medicines. We discussed this with the deputy manager, who told us if a person required medication after 8 pm the deputy or registered manager would return to the service to administer it. This arrangement placed people at potential risk of experiencing avoidable pain, discomfort, or a delay in receiving time‑critical medicines while waiting for a manager to arrive.

This contributed to a breach of regulation relating to safe care and treatment, the need for consent, person-centred care, staffing and good governance.

Systems were in place to audit medicine practices, and records were maintained to document when medicines were administered or refused. Staff confirmed they had received training in the safe administration of medicines.

We saw staff administering people’s medicine sensitively, and one person was observed asking for pain relief. Relatives did not raise any concerns regarding the safe administration of people’s medicines. One relative said, “I have never been told there is a problem.”