Butterley House

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We identified 3 breaches of the legal regulations under the safe key question. Our rating for this key question has changed to requires improvement. The service did not always learn from incidents or act to fully mitigate the potential risk of harm, including identifying and referring safeguarding concerns. Risks to people were not always identified or robustly assessed. The service did not always involve people in decisions about their care and treatment or support. Medicines were not managed safely, and people did not always receive their medicines as prescribed. Staff had not received all the required training to carry out their roles.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and relatives were not always satisfied the service managed safety concerns were effectively. Relatives told us they were not always informed when their loved one was involved in an accident or incident. One told us, “I can’t be sure that I am told about all of the falls.” And a relative said, “Staff here don’t listen to me and didn’t tell me about [relative’s] big fall. The communication is rubbish.”

Whilst staff could explain how they would support someone who had fallen, staff did not always follow the providers policy regarding falls management. For example, not all accidents and incident forms were fully completed.

Systems to review accidents and incidents impacting on the safety of people using the service were not effective. Themes and trends were not identified, and management did not effectively review or sign off accidents or incidents in line with the provider’s policy. This placed service users at risk of harm as lessons were not always learned and action to mitigate risks were not always identified or implemented.

People and their relatives could not recall being involved in planning their admission and transition into the service. One told us “They did do an assessment, but I haven’t seen the Care Plan.” Another said, “I’m not sure they did an assessment before moving, this relative used to live with us.” And “There was no transition plan to move here.” Some relatives spoke positively about individual staff and their efforts to make the transition into the service a positive experience.

Leaders had introduced an admission and discharge form to support safe and effective transitions, however this had not yet been used at the time of our assessment. Staff told us their systems for sharing information included handover and a communication book. They reported this was an effective way to learn about people’s needs and risks.

Partner agencies were working closely with the service to drive improvements after concerns were identified about the quality of care people were receiving. There had been lack of assurances that timely improvements had been made.

Assessments of people’s needs did not always proactively manage risks. For example, one person’s risk assessment had identified they were at risk of attempting to use the stairs. There was no guidance to support staff in what to do if the person did attempt to use the stairs. There was no evidence people, or their families had been involved in the assessment process. Some people’s care plans contained duplicate information, showing a lack of person-centred care planning. Referrals to relevant healthcare professionals were not always made in a timely manner. For example, referrals to falls teams were not made until after our site visit despite some people falling on multiple occasions.

We received mixed feedback from relatives regarding their family member's safety. Some relative's told us about incidents that had occurred where they felt people's safety had been compromised. Some relatives explained poor communication from the service meant they did not know who they could speak to if they had concerns about safety. One relative said, “They tell me nothing.” Overall, other people and relatives felt the service was safe. One relative told us, ““My relative is emotionally safe.” A person said, “I’ve been here for a long time, and I am not worried or frightened.”

Whilst staff confirmed they had received safeguarding training and were able to explain the provider’s safeguarding policy and procedure, we could not be fully assured staff followed this policy. This was because staff had not always recognised when incidents should have been reported to the local safeguarding authority following the recording of accidents or incidents. Leaders explained they were working alongside the local authority to review all open safeguarding investigations.

The communal lounge had a key code which meant it could be locked. In addition, people had key safes outside their bedrooms which were locked when not in use. This meant people relied on staff to access these rooms. We received mixed feedback on the rationale for these restrictions. The communal lounge was not observed to be locked during our assessment. However, people were observed to be comfortable in staff presence. People were observed to have developed friendship groups and positive relationships with others and some staff. Overall staff responded to people kindly, and patiently.

Systems and processes to ensure people were protected from the risk of potential abuse were not always effective. During our assessment we reviewed accidents and incidents and identified an incident which should have been referred to safeguarding. However, there had been no review of this incident and therefore the provider had not made the referral at the time or investigated the incident. We could not be assured any action had been taken to ensure people were protected from the risk of potential abuse. At the time of our assessment, it was unclear whether everyone had the appropriate safeguards in place where they were unable to consent to living at the service. Deprivation of Liberty Safeguards (DoLS) had been applied for less than half of the people living at the service, despite staff and leaders telling us that most people would not have capacity to consent to living at the service. Following our on-site assessment the manager reviewed and made appropriate applications for DoLS.

People and relatives had not been involved in creating or reviewing their care and support plans. One relative told us, “I have not seen the care plan and it hasn’t been reviewed.” Another said, “I don’t know how they reduce risks. My relative did have a walking stick but not anymore so a family member got them a new one.” A person told us, “I am not involved with the care plan, I don’t think anybody is.”

Staff knew people’s individual needs and could tell us the support people required. However, this was not always reflected in written records. Leaders explained care plans and risk assessments were in the process of being reviewed and updated. Staff understood plans were in place to improve care plans but felt those in place lacked person centred information. One staff told us, “They were rushed and poorly written, they are generic and basic, you should be able to know exactly what support people need. They are improving but it is a long process.”

People were not always supported to fully manage their needs and risks. For example, we observed people mobilising without equipment, glasses, or one to one support as their care plan stated they required. It was not always clear how measures to mitigate potential risk had been assessed on an individual basis. For example, at mealtimes most people were using plastic plates and cups. When asked why, staff told us “Because of dementia.” This failed to consider people’s dignity or preferences.

People’s care and support plans did not effectively identify, assess or mitigate risks to people. Care plans did not provide consistent guidance for staff to support people’s risks safely. For example, one person had diabetes. Whilst their risk assessment stated they did not require support to measure their blood sugar levels, their associated care plan stated staff were to monitor blood sugar levels. Furthermore, there was no guidance for staff on what a normal presentation looked like for this person, or how to identify signs and symptoms of poor diabetes management. Another person had a catheter and needed support to manage this safely. They had no risk assessment in place relating to the management of their catheter. This placed them at risk of harm. Care plans were not reviewed regularly, or as needs changed. For example, following falls. Daily records of care did not always demonstrate people’s support had been provided in line with their assessed needs. For example, there were gaps in re-positioning records which meant we could not be assured a person had been re-positioned regularly to maintain their skin integrity as they were high risk of skin breakdown. Care records did not demonstrate people, or their relatives had been consulted with about their support.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Not everyone felt there were enough competent staff. One relative told us, “Often there are no staff, and frequently other residents will ask me to take them to the toilet when I visit. This is not uncommon.” Another said, “It falls down with having too few staff and it’s got worse in the last 9 months. The care was more professional now it is slapdash. The staff aren’t qualified enough.” And, “They need more staff for people with dementia.”

The tool used to calculate staffing levels had not been used since August 2024 or understood by current management. They confirmed it had not been reviewed following any changes in service user numbers, or needs. This meant they could not be assured the staffing levels were safe and appropriate for the needs and numbers of people using the service. Following our on-site assessment, leaders re-assessed people’s levels of dependency which was used to inform staffing levels. Overall staff felt staffing levels were safe and sufficient. One staff told us, “Staffing can be hit and miss but what we have now is OK.” Staff confirmed they received regular supervisions and felt supported by leaders in their role.

Communal areas were not always supervised. We had to alert staff using the emergency call bell to a developing incident between 2 people as no staff were present in the lounge at the time. Staff responded quickly. However, we found staff were responsive to people’s requests for support. Staff did not appear rushed. Some staff took time to talk to people and check in on their well-being.

Training records showed not all staff had completed the relevant training to carry out their roles safely. Staff had not received any specific training to meet the clinical needs of people using the service, despite supporting them to manage these needs. For example, staff had not completed catheter care training or diabetes training. This placed people at risk of receiving unsafe care. Staff had received competency assessments, for example in relation to medicines. However, we could not be assured these were effective as we identified significant issues with medicines management. We identified some gaps in recruitment records, which had been identified by the provider’s own audits. However, no action had been taken to address these. This meant we could not be fully assured robust recruitment checks had been carried out to make sure staff were suitably experienced and competent for the role.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives provided mixed feedback on the management of medicines at the service. Some relatives reported missed medicines, others were not aware of medicines their loved ones received and others raised no concerns. Staff did not always explain to people what their medicines were for. One relative told us, "I don’t think my relative has got a clue about their medication; the staff don’t explain it." Medicines that needed to be given at specific times, such as medicines for Parkinson’s disease, were not given at correct times. We observed doses being given over an hour late. This placed people at increased risk of falls and a decline in their condition. It was not clear if medicines that needed to be given at specific times, or required certain interval between doses had been followed, entries recorded on medicine administration records (MAR) reflective of the actual times of administration.

Staff informed us that they often had issues with the pharmacy not always sending people’s medicines in a timely manner and they frequently had to chase missing items. However, they knew the process to follow if an ad-hoc medicine was needed, and what to do if a medicine was needed urgently. Staff explained the electronic system relied on staff manually inputting entries rather than automatically generating prompts, for example every time a drink was offered, to record how much thickener was given. Whilst staff could explain the process to follow in the event of a medicines error, we were not assured staff followed the provider policy as not all medicine errors had not been reported or acted upon at the time of our assessment. Leaders explained they had increased oversight and audits of medicines following a medicine related incident. Similarly, leaders explained they had completed recent competency assessments on staff who administered medicines. We were not assured the checks were effective in identifying concerns or driving action. The monitoring of medicines and medicines audits had failed to adequately identify all concerns found during our assessment and failed to take adequate action where concerns had been identified. This placed people at risk of harm.

Medicine administration records did not always show people had received their medicines as prescribed. Staff did not always record reasons why a person had a missed dose, for example if is was refused or unsigned for in error. People who had a variable dose prescribed, such as 1 or 2 tablets, staff did not routinely record the dose that was administered. People that needed to have their medicines hidden in food or drink and administered ‘covertly’ did not have robust paperwork in place or pharmacist input to ensure these medicines could be administered with food or drink. Fridge and medicine room temperatures were not documented in line with national guidance, which would impact on a medicines effectiveness if not stored correctly. Staff explained thickener which some people needed in their fluids to minimise choking risks should have been documented when given on the electronic care notes, however we found no documentation to ensure this had been given safely as prescribed with fluids. Similarly, topical creams that were prescribed had to be manually inputted into the electronic care records. It was not clear if all creams had been applied, plus where and when, especially if people were on numerous different creams. When we looked for a person’s steroid cream administration, we could not see this had been applied. People that were prescribed as and when required (PRN) medicines did not have clear protocols in place for staff to follow. Some PRN protocols were still in place for medicines which were no longer prescribed. Doses were not included on the protocols so staff would not be aware what dose to give for maximum efficacy. This placed people at risk of receiving their medicines unsafely.