Devon 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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 had a proactive and positive culture of safety. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had effective systems to record, review and learn from incidents and accidents. Managers used an electronic system to analyse incidents and carried out thematic reviews to identify trends and areas for improvement. This supported ongoing monitoring of safety and helped reduce the risk of repeated incidents.

Staff and leaders took a structured approach to identifying and sharing learning. Lessons learnt records included details of incidents, actions required, route cause analysis, responsible persons and evidence of completion. Staff had read and signed relevant records, demonstrating learning was communicated across the team. This learning helped staff adapt support approaches and reduce the likelihood of similar incidents occurring again.

The provider used incidents as opportunities to reflect on care and make improvements. For example, following an incident involving peer-on-peer aggression, the service reviewed activities, environments and materials that could increase risks. Staff told us incidents were discussed during handovers, debriefs, team meetings and supervision, and that they reflected on people's triggers and what could be learnt from events. This supported a culture of continuous learning and helped staff respond more effectively to risks.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked with people, relatives and partner organisations to plan safe transitions. Records showed transition meetings took place before admission, where information was shared, discussed and reviewed with relevant professionals. Referrals to commissioners and healthcare professionals were made in a timely way to support continuity of care. This helped support planned transitions that considered people’s individual needs.

Staff communicated information effectively to ensure people received consistent support. Records showed information was shared through handovers, staff meetings, debriefs and a communication book. We observed staff discussing planned activities and transitions during handovers, and staff told us care information was reviewed and updated as they got to know people better. This supported safe and coordinated care during periods of change.

The service adapted transitions to reduce anxiety and promote positive outcomes. People were involved in transition planning using communication methods appropriate to their individual needs. Staff used social stories and personalised visual tools, such as ‘Now and Next’ boards, to help people understand upcoming changes. People were supported to become familiar with new environments through visits, photographs and phased transitions. Relatives spoke positively about the approach, with 1 saying, "Transitions are a nightmare for [person] but staff manage [person's] behaviours as well as they can do." This reduced distress and supported people to feel more settled and safer during transitions.

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 systems in place to identify, report and respond to safeguarding concerns. Records showed safeguarding referrals were made to relevant authorities in a timely manner when concerns met safeguarding thresholds. Safeguarding matters were recorded and tracked, including actions taken and outcomes. This supported effective oversight and helped protect people from harm.

People's rights were protected because the service worked within the principles of the Mental Capacity Act 2005. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care services, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). Records confirmed appropriate DoLS applications had been submitted where required and any associated conditions were being monitored. This helped ensure people's rights were protected whilst they received the support they needed.

Staff understood their safeguarding responsibilities and received appropriate training. Training records confirmed staff had completed safeguarding and Mental Capacity Act and Deprivation of Liberty Safeguards training. Staff were able to describe different types of abuse and knew how to report concerns both within the organisation and to external agencies. Leaders reinforced safeguarding through supervision, handovers and team meetings, where learning was routinely shared. This supported a culture where people's safety remained a priority.

People and those important to them were involved in decisions about their care and protection. Relatives consistently told us they consulted about important decisions and felt people were safe. A relative told us, "Everything they do is amazing. I feel safe knowing [person] is there." We also observed staff providing support in ways that promoted people's safety and wellbeing. This demonstrated people were supported by staff who understood safeguarding and valued their rights, choices and safety.

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.

Staff assessed and managed risks in a personalised way. Risk assessments covered people's individual needs, including risks associated with seizures, choking, self-injurious behaviours and community activities. Assessments included guidance on managing risks, escalation procedures and actions staff should take to keep people safe. Risks and support strategies were reviewed regularly to ensure people could continue to develop independence safely. This supported consistent and safe care while promoting people's wellbeing.

The service used a range of tools to help staff understand and respond to people's needs. Positive Behaviour Support plans contained detailed information about triggers, proactive strategies and support during periods of distress, and staff had access to summary guides for quick reference. Communication passports, social stories and other personalised tools were also used to support people. This helped staff provide care that reflected people's individual needs and supported safer care.

Staff balanced safety with people's rights and independence. We observed staff responding proactively to potential risks while avoiding unnecessary restrictions. For example, staff supported a person safely during an activity by ensuring their safety without preventing them from participating in a way they enjoyed. Leaders told us they had reduced restrictions around kitchen access by introducing more person-centred approaches to risk management. Relatives and staff also described personalised strategies used to reduce risks associated with specific health and behavioural needs. This demonstrated people were supported to take positive risks and live meaningful lives while remaining safe.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Some environmental risks had not been identified or addressed through the provider's oversight systems. During the inspection we found the boiler room within the laundry area was not locked and contained exposed hot pipes and nails. Although the laundry was locked and accessed with staff support, individual risk assessments had not been completed for people using the area, chemicals were accessible and hot water warning signage was not displayed. Managers took immediate action by locking the boiler room, introducing signage and completing individual risk assessments to support safer use of the laundry facilities. This demonstrated environmental checks had not always been effective at identifying all risks associated with people's use of the environment.

There were also gaps in wider environmental monitoring arrangements. We found several wardrobes that were damaged, unstable or not adequately secured to walls. Monitoring of environmental and water temperatures was not always fully completed, and the service did not have a process for routinely checking furniture remained secure. This meant some environmental risks had not always been identified and addressed through routine monitoring systems.

Fire safety arrangements were generally well managed, although some records required improvement. Personal emergency evacuation plans (PEEPs) were detailed and up to date but did not consistently include information about staffing requirements, room locations or nearest exits. Actions identified in a fire risk assessment relating to manual call points remained outstanding beyond the provider's planned completion date. Environmental risk assessments were otherwise comprehensive but had not considered people's use of the laundry until this was identified during the inspection.

Staff had completed relevant health and safety training, required servicing and safety certification were up to date, and fire drills and legionella management checks were completed regularly. We observed appropriate adaptations to meet people's needs, including air conditioning, secure radiator covers and personalised environmental adjustments. Relatives spoke positively about the environment, and managers took immediate action to address issues identified during the inspection, including securing wardrobes and strengthening auditing arrangements. This demonstrated a commitment to improving safety and reducing risks for people.

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 had safe recruitment processes and deployed sufficient staff to meet people's needs. Recruitment records included employment histories, references, Disclosure and Barring Service (DBS) checks and proof of identity. Staffing rotas demonstrated enough staff were available to support people safely, and low use of agency staff helped ensure people received support from a consistent staff team who knew them well. We observed staff available throughout the home supporting people with activities and individual needs. This meant people received safe and timely support from suitable staff.

Staff had the training and skills needed to provide effective care. Training records showed staff completed mandatory training as well as additional training relevant to people's needs. We observed staff communicating effectively with people and adapting their approach to meet individual needs. Relatives told us staff were knowledgeable and professional. One relative told us, "First and foremost they understand autism. They are a specialist home." This supported positive outcomes for people receiving care from competent staff.

The provider supported staff through regular supervision and performance management. Records showed staff received supervisions and appraisals at planned intervals. Staff spoke positively about teamwork and support, with a staff member telling us, "There is enough staff and we work as a team." Leaders were visible during the inspection and available to provide guidance when needed. This helped ensure staff were supported to deliver safe and consistent care.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Some infection prevention and control (IPC) risks had not been identified or addressed through the provider's monitoring systems. During the inspection we found a small number of areas requiring improvement, including unclean bathrooms, toilets, shower areas and sinks in people's bedrooms. We also found cleaning equipment stored in an unclean external container. Cleaning schedules were in place and had been completed; however, these had not identified the concerns observed during the inspection. Whilst we could not establish whether the issues were longstanding, the provider's monitoring arrangements had not been effective in identifying and responding to the concerns present at the time of inspection.

There were also some gaps in food hygiene and infection control oversight. We found food storage containers that were not labelled appropriately, including 1 displaying an out-of-date ‘use by’ label and others with no labelling. This meant important food storage information was not always clearly available. Internal audits had identified some concerns, and action plans had been developed. However, records did not always demonstrate actions had been completed or embedded. This meant the provider could not always be assured opportunities to improve infection prevention and control arrangements had been consistently acted upon.

The provider had several measures in place to reduce the risk of infection and responded positively to concerns identified during the assessment. Communal areas appeared clean and well maintained. Staff had completed relevant training and knew how to respond to outbreaks. Staff told us there was always sufficient personal protective equipment available and we observed staff using personal protective equipment appropriately. The service also had clear policies and an allocated IPC lead. This showed the provider had established IPC arrangements and was taking steps to further improve standards.

The provider had systems in place to support safe medicines management. However, improvements were needed to ensure records and monitoring arrangements consistently provided assurance that medicines were administered and stored safely.

Systems for the safe management of medicines were not always effective. We found a person prescribed time-specific epilepsy medicine did not have the administration times recorded on their Medicines Administration Record (MAR) chart. Staff told us they knew the required administration times and that they administered people’s medicines at the correct time, however there was no formal system in place to ensure these medicines were always given at the prescribed times. This meant the provider could not be assured time-critical medicines would always be administered at the required times.

There were also gaps in medicines temperature monitoring. Room temperatures were recorded once daily. During the inspection, we found thermometers within the medicines room were displaying different temperatures and there was no evidence the discrepancy had been identified or reviewed. Although the recorded temperatures remained within the recommended range, this reduced assurance that temperature monitoring arrangements were consistently reliable. In the annex medicines room, minimum and maximum fridge temperatures had not been recorded on multiple occasions during July 2026. Medicines were stored securely and no concerns were identified with stock levels or expiry dates.

Leaders responded promptly when concerns were identified. Following feedback during the inspection, the deputy manager contacted the pharmacy and arranged for MAR charts to include specific administration times. Leaders also reviewed temperature monitoring arrangements and addressed issues identified within the medicines room. This demonstrated leaders were responsive and took immediate action to reduce risks when issues were highlighted.

Staff had completed medicines training and annual competency assessments, medicines audits and reconciliation checks were completed regularly, and people's medicine profiles and as and when required (PRN) protocols contained detailed personalised guidance. We observed people being supported to take their medicines in their preferred way and relatives told us staff kept them informed about medicine administration. The service also promoted the principles of Stopping Over Medication of People with a Learning Disability, Autism or Both (STOMP), and sedative medicines were used only as a last resort. This demonstrated the provider had established systems to support safe medicines management and acted promptly to address areas for improvement.