Burrow Down Shortbreaks

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 regulations in relation to safe care and treatment, and good governance.

This service scored 50 (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. Lessons were not always 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. However, we found the provider had been slow to act upon fire safety concerns identified in August 2025. When we returned to the service, we found maintenance staff were on site, addressing outstanding actions.

Systems and processes had not been fully developed or embedded to ensure safety concerns were identified or that learning was shared. For example, the registered manager was not aware that some risks relating to people’s care needs had not been assessed and told us there had been little feedback following a recent assessment at one of the provider’s other services. This contributed to a breach of regulations in relation to safe care and treatment, and good governance.

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. For example, the registered manager and staff team had developed good working relationships with partner agencies, which enabled the effective sharing of information and promoted good outcomes for people.

The registered manager described the respite transition process, which involved multiple visits led by the person and their relatives, as appropriate. This enabled both people and staff to get to know each other before staying overnight. A relative said, “The transition to here was done slowly. I stayed for the first visit, and after that, I dropped my relative off, and they stayed a bit longer. All in all, it took about 3 weeks, and they were happy to stay the night. I can’t think of anything they could do to make it better.”

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 can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through the Mental Capacity Act 2005 (MCA) application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service.

The management team told us they had applied for DoLS for all people using the service, as they were subject to constant supervision and were not free to leave the service by themselves due to safety concerns. The registered manager confirmed people’s capacity to consent to these arrangements had been assessed, but they had not followed a best interests process, nor had these restrictions been linked to people’s support plans or risk assessments. This contributed to a breach in regulation in relation to the need for consent, safe care and treatment and good governance. Please see the involving people to manage risks, consent to care and treatment and governance sections of this report.

There were systems in place to protect people from abuse, including policies and procedures and training for all staff. Staff understood how to protect people from any form of discrimination and were aware of their responsibilities to report concerns about people’s safety. A staff member said, “I would report the matter to management if I had any concerns or witnessed abuse, and if nothing happened, I would report to the safeguarding team if I needed to.”

Relatives had confidence in the service, the staff and told us their loved ones were safe. Comments included: “My relative is safe, they [meaning staff] are kind and caring and show respect for dignity. I am happy with all that they do,” “I wouldn’t send them there if I didn’t think they were safe,” and “The staff are amazing. I cannot praise them enough.

The provider did not always work well with people to understand and manage risks.

The service’s approach to risk management was inconsistent. People were not always protected from the risk of harm, as staff did not always have all of the information needed to meet people's needs safely. For example, one person had been diagnosed with Epilepsy. There was no care plan or risk assessment in place to support staff in delivering effective epilepsy care. Another person required the use of bedrails to maintain their safety. Staff failed to carry out a bedrail risk assessment. The use of bedrails without [bedrail protectors] had placed this person at an increased risk of entrapment.

Where risks had been identified, it was unclear what action had or was being taken to mitigate those risks and keep people safe. For example, one person had a known risk of overeating, another a risk of consuming non-edible items. However, we found their care records did not contain an assessment of risk or provide sufficient guidance for staff on how to manage or mitigate them.

Whilst we did not identify anyone who had come to harm, the 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, there was limited information to show how staff supported people to be involved in the development of their care and support or reviews.

Relatives did not raise any concerns about people’s safety. One relative said, “Our relative is safe emotionally and in every aspect.” Another said, “They know people well. My relative gets on better with some of the others, but the staff do keep apart to mitigate any risks of challenging behaviours.

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.

Regular checks were carried out on the environment and the maintenance of equipment. However, we found the provider had been slow to address fire safety concerns.

During our tour of the service with the registered manager, we noted some windows throughout the premises lacked suitably robust, tamper-proof restrictors, which are required to comply with health and safety legislation. We raised this with the manager and requested immediate action to ensure people’s safety. When we returned, restrictors had been fitted.

We also observed some external doors were unlocked and had no device to alert staff if someone left the building unattended. This was concerning because the registered manager told us they had applied for DoLS authorisations to restrict people’s ability to exit from the building without supervision, as some individuals would not be safe if they left without support. This contributed to a breach of regulation relating to safe care and treatment.

The service was clean, spacious, and homely. There was a lounge, a large kitchen, and a dining area where people could socialise. A second large activity room with kitchen facilities was available for people to use, and an enclosed garden provided additional space for relaxation. Relatives we spoke with did not raise any concerns about people’s living environment.

People were not always protected by safe recruitment practices. We reviewed recruitment records for 3 staff members. While some checks had been completed, others were missing. For example, 1 person who started in October 2024 did not have any references on file. Another person, who started in January 2025, had only one reference. A third person had a risk assessment in place as mitigation for a delay in obtaining references; however, this was dated after the references had been obtained.

The registered manager told us recruitment checks were carried out centrally. The provider was aware some documentation was missing and was taking action to address this. This information contributed to a breach of regulations relating to recruitment and good governance.

Other recruitment checks were in place. For example, Disclosure and Barring Service (DBS) checks were completed before staff started working at the service. DBS checks provide information, including details of convictions and cautions held on the Police National Computer, which helps employers make safer recruitment decisions.

The registered manager told us all staff completed an induction and did not work unsupervised until they had been assessed as competent. However, there were no records available to confirm inductions had taken place or staff competencies had been formally assessed prior to new staff working without supervision. The registered manager recognised there were shortfalls in the induction process and described the action they had taken to create a new support worker 90-day support plan, which formed the basis of the staff induction moving forward.

Records showed staff had received training in a range of subjects relevant to their roles. Staff we spoke with confirmed they attended training and received regular supervision. One staff member said, “Yes, the managers are always observing, and they prompt us on the training. I had a supervision with [Registered manager’s name] a few weeks ago.” Another said, “Definitely yes, I feel supported and [Registered and Deputy managers’ names] are always checking in and they give praise and support in meetings, and they are always really helpful, and I never feel I cannot go to them and they always give advice and stuff.”

Whilst we did not identify any concerns with staffing levels at the service, we have not assessed staffing levels at the unregistered location.

Relatives did not raise any specific concerns about staffing levels or their competence. One relative said, “There are enough staff, and I presume they are all trained and experienced.” Another said, “The staff are amazing and are all calm; I cannot praise them enough."

The provider did not always assess or manage the risk of infection.

Poor infection control procedures and the absence of clear workflow systems to separate clean and dirty laundry increased the risk of cross-infection. For example, people’s dirty laundry was placed in red bags and left on the floor in the laundry area, bedrooms, and the office.

The registered manager explained that, due to the nature of the service (short-stay respite), staff did not normally wash people’s clothing. However, they acknowledged the current arrangements for managing laundry were not hygienic and agreed improvements were needed. This contributed to a breach of regulation relating to safe care and treatment and good governance.

We toured the service with the registered manager and found it was clean and free from unpleasant odours. Records showed staff had received training in cleaning techniques, infection prevention and control (IPC), the control of substances hazardous to health (COSHH), and the correct use of personal protective equipment (PPE). Staff told us PPE was readily available whenever they needed it.

Relatives did not raise any concerns about the cleanliness of the service.

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.

People’s medicines were not always managed or stored safely. For example, we were unable to check the medicine stock for one person because their medicines had not been booked in. In addition, medicines booked into the service when people arrived were not always located on-site. There was no system in place to record when people’s medicines left the building and were transferred to the unregistered location.

Some people were prescribed medicines to be given when required (PRN). Protocols were in place to guide staff on when to administer these medicines; however, they did not contain sufficient detail to ensure medicines were given consistently and safely.

This contributed to a breach of regulation relating to safe care and treatment and good governance.

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, and their competencies were regularly assessed.

Relatives did not raise any concerns regarding the safe administration of people’s medicines. One relative said, “I order the medication and take it over to them. They let me know if they are running short.” Another said, “There have been no medication errors.