Devonshire House and Lodge

On this page

• 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 remained Good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service had audit systems that had been increased following issues with medication administration from mid May to mid June 2026. The provider’s audit had not recognised serious issues with the administration of medication in the service until 4 weeks after the transfer of medication ordering and delivery from one pharmacy to another had taken place. The provider had been responsive when the pharmacy change took place in mid May 2026, but afterwards had not been proactive in recognising and supporting the service with this challenge in the weeks following this major change.

The new service leaders and existing provider leaders had worked hard in the 6 weeks before the assessment to improve the audit, support and communication systems in the service so there was no re occurrence of the issues with medication administration. They had also introduced additional audits to identify any other issues in the maintenance of the buildings and the quality of the service, so any issues would be addressed promptly. The culture of learning and safety in the service was being actively improved by the service leaders with the support of the provider’s management team.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The difficulties arising from the recent medicines concerns had strained both the resources of the provider and service, and relationships between health partners and the service. These relationships of trust had been damaged and the service recognised a proactive, sustained and open approach from the service and provider was needed to regain this trust.

The service had a close working relationship with the local acute and community NHS Trusts. This was primarily for discharges into their care from acute hospital but also occasionally for admission to hospital. The service worked closely with 2 local GP surgeries. These surgeries worked with the service to maintain active support of people receiving nursing care and those with lesser residential care needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The provider had shared issues quickly and appropriately with the health and social care system. When the failures in the administration of medication were identified by the provider appropriate safeguarding referrals were made. The provider was cooperating constructively with the resulting whole service safeguarding process. The provider had informed people using the service and their families both by letter and in meetings, about the safeguarding process.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found all those who used the service and did not have capacity to make informed choices, had a DoLS application where required, or approved order, in place.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments relating to the health, safety and welfare of people using the service were completed and updated. There was equipment available to help people manage risks safely, such as pressure mat sensors. This equipment was appropriately risk assessed and best interest decision processes used where people did not have capacity to consent to their use.

Where people had capacity and wished to do so, and their relatives if desired, were involved in care planning and risk assessments.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was adequately maintained. They made sure equipment, facilities and technology supported the delivery of safe care. Some fixtures in the home were planned for replacement. Facilities, equipment and technology wereused for their intended purpose and consistently supported staff to deliver safe and effective care.The service had effective arrangements to monitor the safety and upkeep of the premises, bringing in professionally qualified people to complete the necessary environmental and equipment checks.

The provider was investing in the building and its facilities. For example, there were hanging flower baskets and comfortable seating in corridors. This not only gave more places for people to stop and rest when walking but also helped to make these areas feel more like a domestic home.

The home had 2 lifts that enabled access to every room above ground floor level. Some access was restricted by keypad locks on external doors, between units, and out of the garden areas. These restrictions were in place to keep people safe. Peoples’ rooms were personalised with their own belongings including pictures and ornaments. People had access to 2 wheelchair accessible gardens at the service. These provided comfortable and secure areas for people to be outside.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider was investing in the numbers of staff on duty, their roles and their skills. The service was using a staffing level dependency tool to identify an adequate level of staffing. The staffing being delivered was adequate to meet people’s needs.

Care staff were deployed effectively over the 5 units in the building to meet people’s needs. Care staffing numbers and roles were identified for each unit to meet the specific level of need in each individual unit.

There was a new call bell system in place. Call bells were answered promptly, and to cancel the call bell staff had to enter the person’s room. This ensured the times recorded to respond to calls for assistance were accurate and demonstrated they were answered promptly.

Staff had completed the extensive mandatory training scheme required by the provider. This included training on both medication administration and competency assessments.Care staff were provided with in person training on how people were to be moved safely using the equipment available in the service.

The provider did not always maintain the cleanliness of the service.

The building was generally clean. Some people commented the service was usually clean. We found some areas that needed additional cleaning and these were largely addressed by our second visit.

The kitchen and kitchenette facilities in the units were clean and tidy. The separate laundry room was adequately maintained, clean and with easily cleanable surfaces. There was an appropriate process in the service for laundry.

Personal Protective Equipment (PPE) was easily available to staff, and they were using it consistently. The PPE clinical waste was being appropriately disposed of using specific waste bins.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Prior to our visit there had been issues with medicines supplies in the home, following a change of pharmacy supplier. This meant that some people had missed doses of their medicines. New systems had recently been put in place for ordering medicines and monitoring levels in the home. At the time of our visit on 4 August 2026, we found people’s medicines had been given as prescribed for them. The new checking system had ensured any low stock items had been identified and ordered. These new systems still needed to become embedded to ensure there are no more issues going forward.

There were improvements being made to the way people’s creams and external preparations were being recorded. Risks had not always been individually assessed for some higher risk medicines such as flammable topical preparations, and medicines used to prevent blood clots. We were told this would be addressed.

There were suitable arrangements for people having medicines in the form of patches to ensure these were used safely and in line with manufacturers recommendations. When medicines were prescribed to be taken ‘when required’ there was information in protocols and care plans to guide staff when these might be needed.

There were suitable arrangements for storage and disposal, including for medicines needing cold storage and those requiring extra security.

Staff had training and competency checks to make sure they gave medicines safely. Regular medicines audits took place; however, these audits had not identified some of the areas for improvements we found. Any errors or incidents were reported and investigated, so systems could be put in place to prevent them recurring, and learning was shared with staff.