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 inadequate. At this assessment, the rating has not changed and remains inadequate. This meant people were not safe and were at risk of avoidable harm.

The service remains 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.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

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.

At the previous assessment in July 2025, we identified failures in applying the DoLS Code of Practice and in establishing effective systems to investigate and report allegations of abuse. These issues contributed to breaches of regulations relating to safeguarding, person-centred care, and good governance.

At this assessment, although the provider had begun working at pace with the local authority to address these concerns, further improvements were still required. As a result, we continued to identify ongoing risks relating to care planning, risk management, restrictive practices, the Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS), as well as staff training and supervision. For example, some people continued to be subject to restrictive practices that were not reflected in their care plans or risk assessments.

The manager confirmed people’s capacity to consent to these restrictions had not been assessed, and staff had not followed a best‑interest decision‑making process. The restrictions had not been authorised by the Court of Protection, and no alternative legal framework had been applied. Additionally, there was no system for reviewing restrictive practices to ensure they remained necessary and proportionate. As a result, the provider could not be assured any restrictions were in people’s best interests. This meant people remained at risk of receiving care that did not support their well-being or protect them from avoidable harm.

While we did not find evidence to substantiate the specific concerns shared with the Care Quality Commission prior to this assessment, the continued failure to follow the DoLS Code of Practice contributed to ongoing breaches of regulations relating to safeguarding, person‑centred care, and good governance.

Staff had received safeguarding adults training and understood their responsibilities. They were aware of the actions to take if they had concerns about a person’s safety or welfare. People did not raise concerns about their care or about the staff supporting them. One person told us, “I’m happy with the staff who support me.”

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.