Paignton care home rated inadequate and placed in special measures

A care home in Paignton has been placed into special measures after inspectors identified serious concerns about safety, staffing and leadership.

The Care Quality Commission (CQC) has downgraded Burrow Down Residential Home from “good” to “inadequate” following an inspection carried out in November and December 2025.

The home, run by Burrow Down Support Services, provides care for autistic people and people with a learning disability. There were 13 people living at the service at the time of the inspection.

The inspection was carried out in response to safeguarding concerns and issues identified at other services operated by the provider.

Inspectors found nine breaches of regulations relating to person-centred care, safeguarding people from abuse and improper treatment, consent, safe care and treatment, safe recruitment, staffing, notification of incidents, dignity and respect, and the overall management of the service.

The CQC downgraded the home’s ratings for safe, effective and well-led from “good” to “inadequate”. The ratings for 'caring' and 'responsive' were not inspected and remain “good”.

The service has now been placed into special measures, meaning it will be closely monitored while improvements are made. The CQC has also begun the process of taking further regulatory action, which the provider has the right to appeal.

Stefan Kallee, CQC’s deputy director of adult social care for the South West, said: “When we inspected Burrow Down Residential Home, we found a poor culture where leaders didn’t ensure people were safe or consistently treated with dignity and respect. Leaders also hadn’t ensured staff understood the importance of choice, control, independence and inclusion for improving people’s quality of life.

“It was clear that staff at all levels didn’t understand how to deliver high-quality support for autistic people or people with a learning disability.

“As a result of this, people weren’t being cared for in line with regulations and best practice guidance. For example, the service was restricting some people’s freedom by not allowing them to leave the home without staff, and by using door alarms and audio monitors to keep track of their movements.

“Staff hadn’t assessed whether people had mental capacity to consent to these restrictions, or whether they were in their best interests, which they should have done to comply with the Mental Capacity Act 2005. This means people’s rights may have been unlawfully restricted.

“Inspectors were equally concerned by the service’s failure to manage risk and the safety implications this could have for people living at the home. For example, one person with diabetes had it detailed in their care plan that staff should seek medical advice if their blood sugar levels went above or below a specific range. Records showed this had happened on 29 occasions when staff hadn’t raised concerns, placing that person at risk of rapid health deterioration.

“We’ve told Burrow Down’s leaders exactly where they must make immediate and significant improvements and we’re monitoring the home closely to keep people safe in the meantime.”

Inspectors also found:

• Senior managers were not recognising safeguarding concerns or taking action to keep people safe and uphold their human rights. Eight incidents should have been referred to the local authority and the CQC, including concerns about financial abuse and degrading treatment.
• Leaders did not provide enough staff or ensure staff had the skills and experience to meet people’s needs. One person who was funded for two-to-one staff support did not consistently receive this level of care.
• The service did not keep families informed or address their concerns. One relative was told there had been an incident involving their loved one and a member of staff but was not given a clear explanation.
• The environment was not always safe. There were no tamper-proof restrictors on upstairs windows, despite a known risk of a person leaving through a window.
• Care and support plans were not always kept up to date, and agency staff had not always read them. This meant staff were sometimes unaware of people’s health conditions or risks.
• Leaders were responsible for a culture where staff did not feel supported or listened to when raising concerns. Issues were not consistently investigated, limiting opportunities to improve care.

The report is due to be published on the CQC website in the coming days.