Burrow Down Community Support

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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 regulation in relation to safe care and treatment, safeguarding, person-centred care, dignity and respect, staffing and good governance.

This service scored 34 (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 always 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. We reviewed a number of accident and incident records and found that accident and incident analysis did not take place. Information was not used to inform the care planning process or update people’s risk assessments, and governance audits, which had been shared with the provider, were not accurate.

The provider had not developed a proactive and positive learning culture in which concerns about safety and quality were identified, listened to, and responded to promptly. For example, staff described a poor culture where they were discouraged from raising concerns, and there was a lack of debrief following incidents. This meant the management team missed opportunities to develop staff skills and/or knowledge, or challenge poor practice. One staff member said, “We were not encouraged to raise concerns”. The nominated individual told us they had identified a poor culture within the service, which impacted the provider’s ability to learn lessons and make positive changes and had recently taken action to address these concerns.

The provider’s failure to effectively operate systems to identify, assess and mitigate risks associated with the health, safety and welfare of people using the service, placed people at an increased risk of avoidable harm. This contributed to a breach of regulation in relation to safe care and treatment, safeguarding and governance.

People who were able to share their views with us told us they felt safe. One person said, “Yes, I do feel safe.” Another said, “I like the staff.” We received mixed feedback from relatives about people’s safety. One relative said, “[Person’s name] is safe because every month the manager tells me how she’s been.” Another said, “I have no reason to think otherwise.” However, some relatives expressed concerns about their loved one’s safety as communication with the service was poor, and they did not feel they were kept up to date when things happened. One relative said, “If you asked me 18 months ago, I would have said yes, and now I’m not sure.” Another said, “There was an incident, something happened at breakfast. [Person’s name] went to the hospital, and they didn’t call me until 12 hours later. I don’t know what had happened.

The provider did not always 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.

We found robust assessment processes were not in place to ensure a safe and smooth transition between services to reduce the risk of avoidable harm to people. For example, the registered manager told us when people moved between services operated and owned by the same provider, they did not assess the person’s needs prior to the move to ensure they were able to meet their needs.

The provider’s failure to ensure staff undertook a pre-placement assessment meant they could not be assured they were able to meet people’s needs before they were admitted. This contributed to a breach of regulation in relation to safe care and treatment and person-centred care.

Other assessments of people’s needs did take place and were used to develop individualised care and support plans.

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.

Systems and processes had not been established or operated effectively to investigate immediately upon becoming aware of any allegation or evidence of abuse. Governance systems and processes, and provider-level scrutiny of safeguarding, did not identify the concerns we found at our assessment. This placed people at risk of abuse and improper treatment. For example, the registered manager and some staff had been aware 2 people had potentially placed themselves at risk of exploitation or retaliation by their own actions, but delayed escalating these concerns to the local authority in accordance with their safeguarding policy, so it could be investigated.

Incident records showed from November 2024 – August 2025, there had been 5 incidents involving people hitting each other. None of these incidents had been reported to the local authority's safeguarding team or the Care Quality Commission. Incident records and care plans for each person contained insufficient information on any action taken by staff to reduce the risk of recurrence or protect people from harm.

Although people told us they felt safe, records showed some staff used punitive practices as a way of controlling people’s behaviour. For example, one person was told to “go upstairs and change, as due to their behaviour, they could no longer go out for dinner.” Another person was told, following a period of emotional distress, “If you want to see your sister soon, then you need to stop having incidents.” This indicated some people had to earn trips out or the right to see their families, rather than being a part of everyday life and their basic human rights.

Staff had received training in safeguarding adults. They were aware of their responsibilities and knew what action to take should they suspect a person’s safety or welfare was at risk. Staff told us there had been a poor culture in the service, where they did not feel listened to or empowered to raise concerns. However, we noted staff did not escalate their concerns to external agencies in line with the providers’ policy and their training.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. When people receive care and treatment in their own homes, an application must be made to the Court of Protection for them to authorise people to be deprived of their liberty. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

The management team did not have a good understanding of DoLS. Some people were subjected to restrictive practices which were not linked to their support plans or risk assessments. The registered manager confirmed, people’s capacity to consent to these arrangements had not been assessed, nor had staff followed a best interests process. These restrictions had not been authorised by the Court of Protection, and there was no other legal basis or framework in place to support their use. There was no system in place for reviewing restrictive practices to ensure they remained the least restrictive option. This meant the provider could not be assured that any restrictions would continue to be in a person’s best interests.

The failure to provide care and support in line with the Deprivation of Liberty Safeguards code of practice, and to effectively establish and operate systems to investigate and report allegations of abuse, contributed to a breach in regulation in relation to safeguarding, person-centred care, and good governance.

People told us they felt safe. Comments included, “Yes, I do feel safe.” “This is my flat. I am happy living here,” and “The staff are ok.” We received mixed feedback from relatives about people’s safety. Most relatives we spoke with told us their loved ones were safe, and they had confidence in the staff supporting them. One relative said, “Yes, because the carers have been around for quite some years. There is a small group of 4.” However, some relatives were not so positive about people’s safety. One relative said, “Following an incident with medication. We sent a letter asking for a meeting as we wanted assurance that this wouldn’t arise again, but we did not receive a response.

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.

People were not consistently protected from the risk of harm. We identified concerns regarding the management of risk in relation to people's assessed needs. For example, incident records for 2 people indicated staff may have used non-approved methods to distract and/or restrain them during incidents. The registered manager was unaware these incidents had occurred or that restraint had been used without an approved plan in place to ensure its safe and appropriate use, in line with good practice guidance.

Where risks had been identified, the provider did not take sufficient action to mitigate those risks and ensure people’s safety. For example, while incidents were reported and reviewed, care records were not consistently updated to reflect the outcomes of these incidents.

The provider’s failure 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 breaches of regulation in relation to safe care and treatment and good governance.

People’s involvement in the development of their care and support varied according to their individual needs and preferences. However, most people we spoke with were unaware of their care plans or associated risk assessments. Relatives told us staff did not actively involve them in the care planning or review process. Comments included: “The last review was when [Person’s name] went in there in 2022. I have not been involved, but I would like to be.” “I am supposed to be involved, but nobody contacts me for the best interest meetings,” and “There was a review just before Christmas. I was meant to go, but nobody reminded me, so I missed it.

Although systems were in place to help people address environmental concerns or raise issues with their landlords, staff did not consistently support people in reporting problems with their living environment promptly. For example, during a visit to one person's home, staff told us the person’s bath had been broken for some time, but we found this had not been reported. Staff at all levels lacked clarity on how to assist people to address or raise concerns in accordance with their tenancy agreements. Additionally, the systems in place to manage general maintenance created confusion around the provider’s responsibilities and who was accountable for ongoing repairs.

Relatives did not raise specific concerns about people’s living environments.

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. Prior to the assessment, the provider’s Director of Operations raised concerns about the services’ recruitment procedures, which led to the suspension of 8 staff members until Disclosure and Barring Service (DBS) checks were completed. DBS checks provide details such as convictions and cautions held on the Police National Computer, helping employers make safer recruitment decisions.

We reviewed recruitment records for 8 staff. While some checks had been completed, others were missing. For example, the provider had not obtained previous employment or character references for 3 individuals, and 1 file contained limited information about the person’s employment history. The registered manager and staff responsible for recruitment demonstrated a lack of understanding of both the provider’s recruitment procedures and the relevant legal requirements. As a result, there was no formal process in place to ensure staff were recruited in accordance with the provider’s policy.

The provider’s failure to establish and operate safe and effective recruitment procedures contributed to a breach of regulation in relation to fit and proper persons employed.

The manager told us there were enough staff to meet people’s needs safely. However, we noted the provider did not have a good understanding of people’s funded support; this meant they could not be sure if people were receiving the care and support they were assessed and funded for.

The registered manager told us all staff completed an induction and did not work unsupervised until they had been assessed as competent to do so. However, there were no records available to confirm inductions had taken place or staff competencies had been formally assessed prior to working unsupervised. Following the assessment, the provider confirmed there was evidence that inductions had taken place between 28th August 2024 and 2nd September 2024, and 4th November 2024 and 6th November 2024.

The provider monitored staff training on a training matrix. Records showed staff had received training in a variety of subjects relevant to their role. However, we found there were gaps in the training staff had completed, and the training provided did not determine practice. For example, staff failed to act in accordance with the Mental Capacity Act and did not escalate concerns to protect people from harm. Additionally, the provider had recruited 4 deputy managers to oversee several support packages, including staff. However, no additional support was provided in terms of supervision or training for these roles.

Records indicated that staff were not consistently receiving regular supervision. Where supervision had taken place, it was not used effectively to assess ongoing competence or to address specific concerns, such as inappropriate language used in people’s records or the application of punitive practices. There was no evidence that staff had participated in reflective practice sessions following incidents. Additionally, there was no documentation to confirm that annual appraisals had been carried out.

We received mixed feedback from relatives regarding staff competencies. Positive comments included: “They [staff] are all so knowledgeable.” “Yes, they do, they have training.” “The ones I have met seem to be well-trained and know how to care for him.” However, some relatives expressed concerns. Comments included: “The new people aren’t trained.” “They can’t find staff.” “Some do and some don’t.” “I don’t always have confidence in their ability to meet [person’s name] needs.”

This contributed to a breach of regulation in relation to staffing and safe care and treatment.

Following the assessment, the Director of Operations for Burrowdown Support Services provided the Commission with a list of people’s funded support and confirmed that this information would now be linked to staff rotas. Staff would be required to complete training annually, and management training was now being delivered to deputy managers.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Records showed most staff had received training in cleaning techniques, the control of substances hazardous to health (COSHH), and the use of personal protective equipment (PPE). Staff reported that PPE was readily available within individuals’ homes and described how they supported people in maintaining cleanliness in their respective properties. Care records provided clear guidance on the use of PPE during personal care, and risk assessments were in place for the handling of cleaning chemicals. However, while most people’s properties were clean, one was not. We saw the bathroom needed cleaning, and heavily stained bedding had been put back on the person’s bed. Additionally, staff were storing the person’s toothbrush in a filing cabinet alongside other items, which was not hygienic. These concerns were raised with the registered manager for immediate attention. This contributed to a breach of regulation relating to person-centred care and the provision of safe care and treatment.

Neither people nor their relatives raised concerns about the cleanliness of their homes.

The provider did not always make sure that 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, at 2 of the locations we visited, medicines were not stored securely, allowing access by staff who were not authorised to do so.

Additionally, we found the approach taken by some supported living locations to assist individuals with their medicines was not person-centred and did not align with best practice guidance. For example, in some cases, medicines were being ordered, stored, and administered centrally, similar to practices within residential care homes rather than on an individual basis, as recommended in supported living settings.

This contributed to a breach of regulation relating to person-centred care and the provision of safe care and treatment.

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

People who were able to share their views with us did not raise any concerns about the way in which they received their medicines. Most relatives we spoke with expressed no concerns regarding the safe administration of medicines. Comments included: “They [meaning staff] always give medication,” and “[Person’s name] has tablets and they give them to her. There are no problems.” However, one relative reported they had submitted a formal complaint to the registered manager following a medication incident, but had not received a response.