You are here

Archived: Devonshire Manor Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 8 September 2020

About the service

Devonshire Manor is a care home that provides accommodation for up to 15 people who need help with their personal care. At the time of the inspection 9 people lived in the home. Most of the people living in the home, lived with dementia.

People's experience of using this service:

At the last inspection, the provider was rated inadequate and placed in special measures. At this inspection, we found the service had not improved and remained inadequate.

We undertook a focused inspection. A focused inspection was undertaken to specifically check whether sufficient improvements in the safety of the service and people’s care had been achieved and to assess whether the manager and provider now had sufficient oversight of the service. At this inspection we continued to have serious concerns about the safety of the service and its leadership.

People’s risks were still not adequately assessed, and staff lacked clear and sufficient guidance on how to support them appropriately. Records did not show that people received the right support with regards to their nutrition, skin integrity, medication needs and overall care.

Fire safety arrangements remained poor and did not ensure people were protected in the event of a fire. Personal and protective equipment was not being used in accordance with Public Health England guidance to mitigate the risks associated with Coronavirus.

Robust staff recruitment procedures were still not being followed and improvements to the way medicines were managed had not been made to ensure its administration was always safe.

The systems in place to monitor the quality and safety of the service remained ineffective. At the last inspection, the provider and manager did not have sufficient knowledge of the care people needed, or their regulatory responsibilities. At this inspection, this remained the same.

This meant people had continued to be exposed to ongoing risks of inappropriate and unsafe care and poor management.

Rating at last inspection and update:

The last rating for this service was inadequate (published 16 January 2020). After this inspection, the provider completed an action plan to show us what they would do and by when, to improve. At this inspection, the provider not achieved the improvements identified in their action plan. Multiple breaches of the regulations remained and the provider’s rating remains inadequate.

Why we inspected:

This was a planned focused inspection based on the previous rating.

Follow up:

Shortly after the inspection, we referred two people’s care to the Local Authority Safeguarding Team for further investigation. We notified the Local Authority Quality Improvement Team of the ongoing failings of the service. We referred the provider to Merseyside Fire Authority due to the fire safety deficiencies identified at the service. We will work with the local authority and Merseyside Fire Authority to monitor progress.

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will also request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service will be placed in special measures. ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will beg

Inspection areas



Updated 8 September 2020

The service was not safe.

Details are in our Safe findings below.



Updated 8 September 2020


Requires improvement

Updated 8 September 2020


Requires improvement

Updated 8 September 2020



Updated 8 September 2020

The service was not well-led

Details are in our Well-Led findings below.