- Care home
Butterley House
We served 2 warning notices against First For Care for shortfalls in identifying and assessing risks, poor medicines management and ineffective governance which placed people at risk of harm at Butterley House.
Report from 30 September 2024 assessment
Contents
Ratings
Our view of the service
Date of assessment: 21 October to 29 October 2024. This assessment was in response to CQC receiving information of concern. We found 4 breaches of the legal regulations relating to safe care, governance, staff training and safeguarding. Improvements were required for the management of safety incidents, safeguarding and care plans and risk assessments. Records were not always accurate, and audits and checks were not always effective at identifying areas for improvement. Provider policies were not always followed. The service did not ensure people were getting their medicines correctly and on time. Documentation was not clear to show all prescribed items were being administered as prescribed. Not all staff had completed mandatory training to carry out their role safely, and staff had not been provided with training to meet people’s specific clinical needs. An interim manager had been recently appointed to drive improvements at the service. Staff were positive about the new leadership team and felt able to raise concerns with them.
People's experience of this service
We spoke with 7 people and 9 relatives of people who used the service. We carried out a short observational framework for inspections (SOFI) which helped us understand the experiences of people using the service who could not speak with us. Not everyone we spoke with felt the service was safe. People and relatives reported poor management of falls at the service and a lack of communication from management. Some relatives felt improvements were required to ensure good partnership working with relevant professionals. People and relatives were not always involved in care planning, and people’s risks were not always safely supported. People and relatives felt staffing levels were not always sufficient and this had an impact on the quality-of-care people received. Some people and relatives reported concerns about medicines management. However, some people felt the service was safe and had positive relationships with some staff.