Burrow Down Residential Home

Burrow Down Residential Home provides accommodation and personal care for up to 14 adults with learning disabilities and autistic people. At the time of our assessment, 13 people were living at the home. This was a responsive, risk-based assessment prompted by concerns identified at other services operated by the provider and a failure to escalate safeguarding concerns. During this assessment, we reviewed 21 quality statements and identified 9 breaches of legal regulations relating to safeguarding, safe care and treatment, need for consent, person-centred care, dignity, recruitment, staffing, notification of incidents and governance.

We found serious and widespread shortfalls in how the service protects people from harm and upholds their rights. People were not always safe, and care was not consistently provided in a way that promoted dignity, independence, and well-being. Systems and processes were ineffective, and leadership and governance did not ensure compliance with regulations.

People were exposed to avoidable harm because risks were not assessed or managed effectively. For example, environmental hazards such as unrestricted windows and poor fire safety checks were not addressed promptly. Medicines were not stored securely.

Staff did not consistently understand or apply the principles of the Mental Capacity Act 2005. Restrictions were in place without lawful authority, and best interest processes were not followed.

Staffing numbers and deployment were not sufficient to meet people’s assessed needs safely. Records showed gaps in training, supervision, and competency checks. Agency staff were used frequently, but the provider could not assure us they had the skills required to support people safely.

Governance systems were ineffective. Audits and quality assurance processes did not identify the concerns we found. There was limited evidence of learning from previous inspections or incidents. Notifications of significant events were not made in line with legal requirements.

At this assessment, the overall rating has changed from good to inadequate. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. In addition, we have requested an action plan from the provider to set out how they will address the concerns found at this assessment.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.