Butterley House

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified 1 breach of the legal regulations under the well-led key question. Our rating for this key question has changed to inadequate. The service was not always well-led. Systems and processes to oversee risk and drive improvement at the service were not always effective. Policies and procedures were not always followed. Feedback from people was not always used to shape the service. Leaders were working to develop a culture where staff felt able to speak up.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Not all staff were not aware of where to access provider policies, which were in place to support compliance with the provider’s aims and objectives. During our assessment we found staff had not always followed relevant policies when carrying out their roles which impacted on the quality of care and safety of people. This showed staff did not always understand and support the visions and values of the service. However, staff were motivated by providing compassionate care. One staff told us, “We are a family unit rather than a care home, staff work together and help each other to support residents.”

There was a lack of opportunities for people to be involved in developing objectives for the service. At the time of our assessment there had been no resident or relative meetings and feedback had not been sought from people who used the service. During our assessment we identified multiple failures to follow provider policy.

At the time of our assessment there had been a recent change in the management team. Staff told us the change had led to improved morale and positive changes. One staff told us “[Interim manager] is fantastic, a breath of fresh air. They like to be in the loop with everything which I think is very good.” Another said, “The management team are visible and approachable. Issues are being sorted [by management] now and it is noticeable.” The interim manager demonstrated an understanding of the issues and priorities for the quality of the service however there had been a lack of development to overcome issues in a timely manner.

There had been an ineffective handover to the new interim manager. We found poor organisation of service documentation. Information was not easily accessible, and the management team were unaware of where some key service documentation was filed, missing some passwords or access to relevant files. This did not demonstrate effective oversight.

Staff fed back positively about the new management team and felt confident to raise any issues with them.

Relevant policies were in place to support people to raise concerns. However, we could not be assured these had always been followed due to failure to identify and report concerns about quality of care which were identified during our assessment.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The interim manager was aware of the provider’s governance systems, but as they were new in post had not had opportunity to review the audit schedule or any actions generated from audits carried out under previous management. Leaders explained they had increased medicine audits to weekly following concerns, however as we identified ongoing concerns during our assessment, we could not be assured this demonstrated effective oversight.

Governance systems and processes were not effective in identifying where quality and safety were being compromised. For example, care plans had not been audited in line with the provider’s audit schedule since August 2024. Daily records of people's care and support and call bell response times were not audited, meaning there was no clear oversight of these areas. The provider failed to act where quality audits identified areas for improvement. For example, a care plan audit dated August 2024 had reviewed 14 areas of a care plan, it failed to identify the care plan reviewed and the actions generated from the audit stated "Some areas of care reviews need more information". This failed to identify which areas needed further information and who was responsible for reviewing and completing the action. There was no evidence this had been addressed. Records relating to the care and treatment of each service user were not always accurate and up to date. For example, one person’s medical history failed to mention they experienced seizures. Many people's care plans and risk assessments had not been reviewed following falls or incidents. This placed people at risk of receiving unsafe care which would not support their needs.

Some people and their relatives reported ineffective partnership working with other agencies and professionals, or poor communication with them following appointments with professionals. One relative told us, “I wonder if my relative needs more as they are becoming more agitated. The home should contact this team. I do not think the staff here works well with other professionals…The office is utter chaos.” Another told us about a request for an assessment by healthcare professionals which had not been followed up for 1 year.

Overall staff reported positive working relationships with a range of professionals. Staff used a communication book to share updates. However, care records were not always updated following referrals or advice from professionals.

The provider was working with external agencies to address issues, however at the time of our assessment there had been a lack of improvement to demonstrate effective action had been taken in response to feedback from external agencies.

The providers systems and processes failed to identify where professional advice was required in line with their own policy. For example, where people had fallen multiple times, it was not always clear if a referral to the local falls team had been made. Following our assessment, the manager ensured all appropriate referrals were made.

An interim manager had been appointed to drive improvements at the service, however they had only been in post for a short period at the time of our assessment and had not been provided with a comprehensive handover, action plan or list of key priorities for the service. They informed us they were aware of issues and planned to address them as they got to know the service. Staff felt overall assured with the new management team to drive the necessary improvements.

The provider was unable to demonstrate a clear and consistent approach in how they were working to make improvements happen. This was because at the time of our assessment there was no service development plan in place to support the delivery of any improvements. Following our assessment, an action plan was created. Processes to ensure learning when things went wrong were not effective. For example, falls and accidents were not fully recorded, robustly reviewed, investigated and analysed. This placed service users at risk of harm as action to mitigate risks were not always identified or implemented.