Devonshire House and Lodge

“The governance systems had failed to identify and rectify significant failures in medication administration in a4-week period from mid-May to mid-June 2026. During this period people were not receiving person-centredcare to meet their needs. Since these events took place, the provider had invested management time, replaced the management of the service and cooperated fully with the resulting whole service safeguarding process led by the Local Authority. The provider had improved their support for the service and for the newly recruited service managers and staff. We found the administration of peoples’ medication was now both safe and the service’s medication systems were operating appropriately.”

“People were protected and kept safe. Staff risk assessed and reviewed people’s needs frequently. People and their relatives were involved in assessments of their needs and planning people’s care. Staff worked with all agencies, including local health and social care services involved in people’s care to achieve the best outcomes.”

“People had enough to eat and drink to stay healthy. People enjoyed a variety of good quality food. Staff monitored people’s health and welfare to support healthy living. Peoples’ care was continuously monitored by the management team with the support of an electronic IT system. Staff worked with all agencies involved in people’s care for their best outcomes.”

“There were enough staff and management team with the right skills, qualifications and experience to meet people’s needs. The provider and management team supported staff wellbeing. Staff felt supported to give feedback and were treated fairly.”

“The provider invested in the building, facilities and fixtures of the service. However, we found some issues of cleanliness and worn-out fixtures. These were being addressed and the provider had planned to make these replacements and ensure cleanliness was maintained in all areas.”

“The provider, new service leaders and staff were developing a new shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. The providers representatives were involved in the day to day working of the service to support the new service management.”