The Devonshire Also known as 1- 3883899011

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 changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 59 (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.

Staff documented accidents and incidents, however not all sections of the forms were always complete . For example, when people experienced falls, the post falls analysis did not always include the form’s required level of detail and follow up actions were not always taken. This meant the provider could not be assured they were doing all that was reasonable to prevent a recurrence, and learning opportunities were missed.

Lessons learnt were completed, however they did not always contain meaningful information about incidents or accidents that had happened. Some of the lessons learnt records were lists of things staff were not doing well, and there was not always a discussion held on how to learn from incidents that occurred in the home. There were not always opportunities for staff discussion, learning and development to help prevent a recurrence, and upskill staff.

Records showed relatives had been contacted when incidents and accidents occurred. A relative told us, “[Person] has had a couple of falls, but I was told straight away.”

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.

Prior to admission into the home, an initial assessment was completed. Where possible, this was completed face to face to ensure the provider could meet the persons’ assessed needs. The registered manager told us they encouraged people and their relatives to visit the home as part of the pre admission process.

Staff understood referral pathways and used them appropriately. This included making referrals to speech and language therapists (SALT) and occupational therapists when people’s needs changed.The provider worked closely with a physiotherapist who visited the home weekly. During the visit they would assess the needs of people recently admitted and make any referrals for additional equipment.

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.

People were protected from the risk of abuse and avoidable harm. All staff received regular safeguarding training. Staff had a clear understanding of their responsibility to report any safeguarding concerns. One staff member told us, “Safeguarding is ensuring and protecting an individual's right to live free from abuse as well as neglect and harm. It covers all aspects of health and welfare inclusive of both physical and mental wellbeing as a human, no matter of ethnicity, gender, religion.”

Daily handover meetings were used to share information and ensure any new risks or safeguarding issues were communicated to staff promptly. The registered manager had reported safeguarding concerns to the local authority and had notified the Care Quality Commission by submitting the required statutory notification.

People told us they felt safe using the service. One person we spoke with told us, “I am safe, I feel safe.”

The provider did not always work well with people to understand and manage risks. Risks to people had been assessed, however some risk assessments required additional detail to support staff in fully understanding the risk.

The provider could not be assured staff were working in line with people’s risk assessments. For example, 1 person’s risk assessment recorded their fluid intake must be limited to help prevent choking. However, staff documented they had offered more than this safe amount on multiple occasions. In response to our feedback, the provider implemented changes to prevent a recurrence.

Risk assessments did not always include sufficient guidance for staff. For example, 1 person’s care plan recorded they had epilepsy. However, there was no guidance for staff about how they should respond if the person experienced a seizure. Another person’s care plan contained contradictory information on the support they required to manage their continence. This meant risks associated with people’s health and personal care needs were not always effectively identified.

People who had specific risks such as diabetes had risk assessments in place which contained clear guidance on signs and symptoms of high or low blood sugars and what actions staff needed to take.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. People were not consistently protected from potential risks. The provider had failed to do what was reasonably practicable to mitigate risks to people.

The provider failed to act without delay and do all that was reasonably practicable to keep people safe in the event of a fire. For example, a fire risk assessment completed in July2024 identified many fire doors were damaged or had excessive gaps, potentially making them ineffective. In June 2025, the local fire service recommended a full fire door survey as some doors were visibly damaged. Again, in July 2025, a fire risk assessment identified some fire doors had excessive gaps, and a fire door replacement programme was recommended. During this inspection, we observed several damaged fire doors, and many doors with excessive gaps. The provider had failed to act promptly in line with fire risk assessments and manage this risk, placing people at increased risk of avoidable harm in the event of a fire. We shared our concerns with the local fire service. In response to our findings, the provider arranged for a fire door survey to be completed.

We observed an environmental risk relating to furniture and equipment. For example, a drawer unit in a dining room had broken handles where sharp screws were exposed. This meant people were at risk of injury if they tried to open the drawers.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, supervision and development.

We received mixed feedback from people and their relatives on staffing levels. One person we spoke with told us, “I find they’re very short staffed here and you have to wait.” Relatives told us they often had to wait to be let into the home, and could wait up to 15 minutes before being let in.

The provider did not consistently ensure there was sufficient staffing in line with their assessed staffing levels. Rotas showed that on multiple days, units were without a senior healthcare assistant or care practitioner. Although additional healthcare assistants were sometimes scheduled, they did not hold the same responsibilities as senior healthcare assistants or care practitioners. This meant there were not always enough senior staff on duty.

Staff we spoke with told us they felt staffing levels were not sufficient. One staff member told us, “During assistance of personal care, most carers are then not on the unit floor because they are in a person’s room or shower room completing personal care tasks. The medication trained member of staff is completing the medication rounds, in turn this results in that there is no member of staff on hand to supervise and support residents that are in the communal areas. Another staff member told us, “It can be difficult, especially around mealtimes. If we have roughly 10 people who need assisting [with eating], there will be 2 [staff] assisting, 1 [staff member] in the dining room and 1 [staff member] in people’s rooms. We don’t always have a hostess on our unit.”

The registered manager had a training matrix in place which showed staff had completed all their statutory and mandatory training. The provider monitored people’s training compliance, where staff had not completed training, reminders were sent with a deadline to complete the training. New staff completed an induction when starting their role.

Staff received regular supervisions, this was monitored by the provider’s supervision matrix.

Recruitment checks were carried out by the provider to ensure staff were safe to work with people. Pre-employment checks included a job application form, an interview, and references. All staff were required to complete an enhanced Disclosure and Barring Service (DBS) check before starting employment. A DBS check provided information about any convictions and cautions held by police.

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.

During the inspection we found several areas of the home were visibly unclean, including a build-up of dust. People’s equipment was not routinely cleaned after each use, during our inspection we found some equipment was visibly unclean and stained. One relative told us, “Now I would say, [person’s] room appears a bit grubby sometimes and could be cleaner.” This meant the provider could not be assured they were doing all that was reasonably practicable to prevent the spread of infection.

Staff undertook infection control training as part of their mandatory training. We saw staff consistently used personal protective equipment (PPE), such as disposable gloves and aprons, when they carried out personal care or assisted people at mealtimes.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely, the provider had systems for ordering, administering and monitoring medicines. Staff were trained and assessed for competency before they administered medicines independently. Medicines were stored safely and records were completed in line with the provider’s policy. Staff monitored room and fridge temperatures to ensure medicines were stored within the correct temperature ranges.

People had as prescribed (PRN) medicines and there were PRN protocols in place, however these did not always contain sufficient guidance for staff to know when they were able to administer the PRN medicines. In response to our feedback the provider told us they would review and update the protocols.