CQC Takes Action to Protect Residents at Paignton Care Home

The Care Quality Commission has taken enforcement action against a care home in Paignton, Devon, following serious concerns about safety, leadership, and quality of care.

Burrow Down Residential Home has been downgraded from ‘Good’ to ‘Inadequate’ and placed into special measures, after inspectors identified widespread failings across the service.

Nine Breaches of Regulations Identified

The inspection, carried out in response to safeguarding concerns and wider issues linked to the provider, found the service was in breach of nine separate regulations.

These included failures in:

• Person-centred care
• Safeguarding and protection from abuse
• Consent and the Mental Capacity Act
• Safe care and treatment
• Staffing and recruitment
• Incident reporting and governance

As a result, ratings for safe, effective, and well-led were all downgraded to Inadequate.

Serious Concerns Around Safety and Rights

Inspectors identified significant risks to residents, particularly in relation to safety and human rights.

Concerns included:

• Failure to act on safeguarding incidents, including potential financial abuse
• Restrictions placed on residents without proper consent or legal assessment
• Poor risk management, including missed medical escalation for a person with diabetes on multiple occasions

In some cases, people’s freedom was restricted through measures such as door alarms and monitoring systems, without appropriate capacity assessments in place.

Leadership and Culture Failings

A key theme throughout the inspection was a poor organisational culture driven by ineffective leadership.

CQC found that:

• Leaders failed to identify or act on risks
• Staff lacked the skills and understanding to support people appropriately
• Concerns raised by staff and families were not consistently addressed
• Opportunities to learn and improve were repeatedly missed

This resulted in a service where people were not consistently treated with dignity, respect, or in line with best practice guidance.

Staffing and Oversight Issues

Inspectors also identified operational failings, including:

• Insufficient staffing levels to meet people’s needs
• Staff not always aware of care plans or individual risks
• Families not being kept informed about incidents or changes in care

In some cases, this led to people receiving care that was unsafe or not aligned to their specific needs.

Regulatory Action and Next Steps

The service has now been placed into special measures, meaning:

• Increased monitoring by CQC
• A clear timeframe for improvement
• Potential further enforcement action if standards do not improve

CQC has also begun the process of taking additional regulatory action, which the provider has the right to appeal.

Why This Matters

This inspection reinforces a critical message across the sector:

Failings in leadership and culture can quickly escalate into widespread risk across every aspect of care.

For providers, it highlights the importance of:

• Acting immediately on safeguarding concerns
• Ensuring staff understand legal frameworks such as the Mental Capacity Act
• Maintaining strong oversight of risk, care delivery, and incident reporting

The Bigger Picture

The Care Quality Commission is placing increasing emphasis on:

• Human rights and consent
• Safeguarding and transparency
• Leadership accountability

Services that fail to meet these standards — particularly where concerns have been raised previously — are facing faster and more decisive enforcement action.

Looking Ahead

For Burrow Down Residential Home, urgent and sustained improvements will be required to exit special measures.

For the wider sector, this inspection serves as a clear reminder: Quality care is not just about delivery — it is about leadership, culture, and protecting people’s rights every single day.

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