- Homecare service
Burrow Down Community Support
Assessment report published 19 December 2025
Contents
Ratings
Our view of the service
Date of assessment: 04 July to 27 August 2025.
Burrow Down Community Support provides care and support to people with a learning disability and autistic people who have general health needs, mental health needs, sensory impairment, or physical disability. The support is provided to people who live in their own homes within Torbay and the surrounding area. Packages of care varied from daily visits to 24-hour care. The service currently supports 50 people, 26 of whom received a regulated activity.
An assessment has been undertaken of a specialist service that is used by autistic people or people with a learning disability. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
This was a responsive assessment as we had received information of concern in relation to the management of safeguarding, management of risk, the application of the Mental Capacity Act 2025, staff training and governance. At this assessment, we looked at 21 quality statements. We found 10 breaches of the legal regulations in relation to safeguarding, safe care and treatment, need for consent, person-centred care, dignity, recruitment, staffing, notification of incidents and governance. This meant people were at risk of receiving care and support that did not promote their well-being or protect them from the risk of avoidable harm.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
At this assessment, the overall rating has changed from good to inadequate. We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People who wished to share their views with us told us they felt safe and were happy receiving support from Burrowdown Community Support. Comments included, “Yes, I do feel safe.” “This is my flat. I am happy living here,” and “The staff are ok.”
Whilst some relatives were happy with the care and support provided to their loved ones, others raised concerns about the lack of leadership and management, poor communication, staffing levels, the use of agency staff, training and competence of staff.
Although many people reported feeling happy, our assessment identified several aspects of care that did not meet expected standards. The provider was unable to demonstrate how they upheld key principles of Right Support, Right Care, Right Culture. As a result, we could not be assured that people using the service were supported to live as full and independent a life as possible or to achieve the best possible outcomes.
Right Support: People were not always supported to have maximum choice and control of their lives, and staff were not supporting people in the least restrictive way possible. The service could not always demonstrate they were acting in people’s best interests.
People were not always protected from the risk of harm, as staff did not always have all of the information needed to meet people's needs safely. People were able to choose how they spent their time but were limited by the availability of drivers.
Right Care: People’s care was not always delivered in a way which met their assessed needs. Most staff knew people well and understood how to communicate effectively with them. However, people were not consistently treated with dignity and respect, and the language used in some care records was disrespectful.
Right Culture: The service was not operating in accordance with the regulations and best practice guidance. There was a lack of insight and understanding from the management team regarding the experience of receiving support from Burrow Down Community Support and the impact this was having on people’s lives. The management team had not created an open and transparent culture, where constructive feedback was encouraged. Relatives knew how to make a complaint but were not confident their concerns would be addressed.