The Devonshire

The inspection was carried out in response to concerns we received about the safe care and treatment of people using the service. A decision was made for us to inspect and examine those risks. We carried out a comprehensive inspection in August 2024, and the service was rated good. At this inspection, we found the provider was in breach of the legal regulations relating to safe care and treatment and good governance. As a result, the rating has changed to requires improvement.

The provider did not have consistently effective fire safety measures in place to ensure people were protected from the risks associated with fire. For example, some fire doors were damaged, and some had excessive gaps meaning they would not be effective in the event of a fire. This placed people at increased risk of avoidable harm in the event of a fire.

While accidents and incidents were documented, not all sections of the forms were completed. The provider failed to ensure follow up actions were consistently taken, and learning was not effectively embedded across the service.

People were not routinely protected from the risk of potential harm; risks were not always identified and mitigated without delay. For example, we observed broken furniture and equipment that was accessible to people.

People’s documentation was not always updated following changes to their needs and support.

The provider failed to ensure checks and audits were used consistently and effectively to identify shortfalls, errors and omissions. When areas for improvement were identified, the provider did not always act and make those improvements.

Staff received safeguarding training and understood their roles in protecting people from the risk of abuse and avoidable harm. The provider raised safeguarding alerts and reported concerns about people’s needs effectively. Staff worked with relevant agencies to investigate and act to keep people safe.

People were supported with their prescribed medicines and referred to external healthcare professionals without delay.

We have asked the provider for an action plan in response to the concerns found at this assessment.