CQC takes action to protect people using Paignton homecare service

The Care Quality Commission (CQC) has downgraded the rating of Burrow Down Community Support in Paignton, Devon from good to inadequate and placed it into special measures to protect people following an inspection in July and August.

Burrow Down Community Support is a supported living service for autistic people and people with a learning disability run by Burrow Down Support Services. The service supports 50 people, 26 of whom received a regulated activity.

CQC carried out the inspection in response to concerns about safeguarding, risk management, the application of the Mental Capacity Act 2005, staff training and how the service was being managed.

Inspectors found that care had deteriorated, and the service was now in breach of nine regulations in relation to safeguarding, safe care and treatment, need for consent, person-centred care, dignity, recruitment, staffing, notification of incidents and how well the service was being managed. This meant people were at risk of receiving care and support that did not promote their well-being or protect them from the risk of avoidable harm.

CQC has downgraded the areas of safe, effective and well-led from good to inadequate. Caring and responsive were not inspected and remain rated as good.

CQC has also placed the service into special measures which involves close monitoring to ensure people are safe while they make improvements. Special measures also provides a structured timeframe so services understand when they need to make improvements by, and what action CQC will take if this doesn't happen.

Stefan Kallee CQC deputy director of adult social care in Devon, said:

"When we inspected Burrow Down Community Support, we found poor leadership that had allowed a closed culture to develop, where people weren't consistently treated with dignity and respect, and where basic rights were compromised.

“Although people told us they felt safe, records showed staff sometimes used punishment to control behaviour. People were told they could be denied outings or family visits unless they behaved in certain ways, meaning basic rights had to be ‘earned.’ These practices revealed a culture that restricted autonomy and undermined dignity.

“Leaders hadn't identified or addressed serious concerns. Staff weren't always protecting people from abuse or harm because leaders didn't spot when things went wrong. For example, since November 2024 there have been five incidents where people hit each other. None of these were reported to the local authority's safeguarding team or to CQC as required.

“People also weren't always supported to have maximum choice and control of their lives. Staff restricted people's access to their own belongings and areas of their homes without checking if they had capacity to consent to these arrangements or following a best interests process.

“We expect adult social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to services that most people take for granted.

“Following the inspection, we sought assurances from Burrow Down that they’d taken action to strengthen oversight and support day-to-day management and told them to provide us with an action plan demonstrating how they’ll drive improvements. They’ve appointed new staff and enhanced training to improve the quality and safety of care provided. CQC will continue to monitor the service and work with system partners closely."

Inspectors found:

• Staff used non-approved behavioural support methods during incidents without proper plans in place, and leaders did not know these incidents had occurred.
• Staff did not always store people’s medicines securely, and unauthorised staff were able to access medicines at two locations.
• Leaders did not always acknowledge or respond to concerns and complaints in a timely manner, and two relatives reported receiving no response after raising formal concerns.
• Leaders did not improve people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.
• Leaders didn’t follow safe recruitment practices, with missing references and employment history checks for several staff members. This meant people were potentially at risk from staff who hadn't been properly vetted.

However, inspectors also found:

• Staff understood people’s likes, dislikes and dietary needs well and provided support that aligned with assessed needs in this area.
• The registered manager told us all staff completed an induction and did not work unsupervised until they had been assessed as competent to do so.

The report will be published on CQC's website in the coming days