You are here

The provider of this service changed - see old profile

We are carrying out a review of quality at Devonshire Manor. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 16 January 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 13 people lived in the home. Some 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 requires improvement. At this inspection, we found the service had deteriorated to inadequate.

There were no adequate or effective systems in place to monitor the quality and safety of the service. This resulted in people being exposed to ongoing risks.

Risks in relation to people’s care were not properly managed and their care did not ensure their needs and preferences were met. This placed people at risk of receiving inappropriate and unsafe care.

People told us that the food and drink on offer was good. We found however that people did not always receive a diet suitable for their needs. Where people needed help from staff to eat their meals, the support provided was not well organised or person centred.

The Mental Capacity Act 2005 was not always followed to ensure people’s legal right to consent to their care was respected. People’s right to be independent and have control over their own care was not always promoted in the support they received.

People living in the home had little to occupy and interest them. Their social and recreational needs were not adequately supported and most people spent all day watching television.

On the days we inspected, staffing levels within the home were sufficient to meet people’s needs. People told us they felt supported and that staff were kind. Staff recruitment however was not safe and some staff had not received the training and support they needed to do their job effectively.

Records showed that some people had raised concerns over staff conduct but there was little evidence that safeguarding procedures had been properly followed to ensure people were protected from potential abuse.

Fire safety arrangements were not robust. There was no formal fire evacuation procedure and practice fire drills had not been undertaken for some time. Staff members had not received training in how to use the home’s fire evacuation equipment and fire alarm checks had also not been completed for over six weeks at the time of our inspection.

The atmosphere at the home was homely but the management of the service was not open, person centred or motivational. Neither the provider or manager had sufficient knowledge of people’s care or their regulatory responsibilities. The service was not well-led and did not ensure people achieved good outcomes or had a good quality of life.

Rating at last inspection and update:

The last rating for this service was requires improvement (published 17 April 2019). After this inspection, the provider completed an action plan to show us what they would do and by when, to improve. At their recent inspection, the provider had not achieved the improvements identified in their action place. We found multiple breaches of the regulations and the provider’s rating has declined to inadequate.

Why we inspected:

The date of the inspection was brought forward due to CQC receiving concerning information about the service and people’s care.


We have identified breaches in relation to regulations 9 (person centred care), 11 (Need for consent), 12 (safe care and treatment), 13 (Safeguarding people from abuse and improper treatment), 14 (Meeting nutritional and hydration needs), 17 (Good governance) and 19 (Fit and proper persons employed.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up:

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 re

Inspection areas



Updated 16 January 2020

The service was not safe.

Details are in our Safe findings below.



Updated 16 January 2020

The service was not effective.

Details are in our Effective findings below.


Requires improvement

Updated 16 January 2020

The service was not always caring.

Details are in our Caring findings below.


Requires improvement

Updated 16 January 2020

The service was not always responsive.

Details are in our Responsive findings below.



Updated 16 January 2020

The service was not well-led

Details are in our Well-Led findings below.