CQC report explained · a nursing home
What the CQC found at Butterfly Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were safer than at the previous inspection. Medicines were recorded and managed safely, but one call bell rang for over 10 minutes and weekend staffing was sometimes reported to be weaker.
- Effective?
- Good
- Staff had training and generally used it well. On a very hot day, drinks were not offered more often and were not always freely available, and staff did not always know who had approved some DoLS applications.
- Caring?
- Good
- People were treated kindly and with dignity. Inspectors found that some people did not always have drinks or stimulation within reach, and some people were not as well groomed as they could have been.
- Responsive?
- Good
- Care plans, trips and social activities had improved, and complaints were investigated. Some care plans had not been reviewed, and information and complaints documents were mainly in written form.
- Well-led?
- Good
- A new manager and operations manager had brought improvements in culture and oversight. However, there was not yet a care plan audit and the wider governance system still needed strengthening.
What inspectors found, June 2019
Rated Good; inspectors found kind, safer care and clear improvements, but records, staffing and personal care still needed attention.
This was an unannounced inspection on 21 and 22 May 2019. Inspectors spoke with people living at the home, relatives, staff, managers and outside organisations. They also observed care and checked care records, medicines, staff files, training, complaints, safety records and audits.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe and received kind and respectful care. Medicines, risk management, safeguarding knowledge, training and activities had improved since the previous inspection.
The inspection still found some gaps. Care plans and risk assessments were not always reviewed or complete. Some people did not always have drinks, stimulation or good personal grooming when spending time in their rooms. Staffing vacancies remained, although agency staff and newly recruited nurses were being used.
Safer medicines
Medicines were now managed safely, including creams, nutritional supplements and medicines used when behaviour was difficult to manage.
“People's medicines were now being managed safely. Medicine administration records (MARs) were now being completed accurately.” from the report
Kind and respectful care
People and relatives described staff as kind, gentle and caring. Inspectors also saw people approaching staff comfortably.
“People told us they were treated with kindness.” from the report
Improved leadership
The new management arrangements were linked with a better culture, stronger staff morale and improvements since the previous inspection.
“The new manager had brought a change of culture and leadership to the service to ensure people's care was delivered in line with the principles of dementia care.” from the report
Better activities
Social opportunities had improved, including daily trips out and involvement in a local school project.
“Since our last inspection, opportunities for social engagement had improved with daily trips out.” from the report
Staff training
Staff had received training suited to people's needs and inspectors saw them putting it into practice.
“Staff were seen to put their training into practice, for example by supporting people safely with their meals, and by sensitively offering emotional support.” from the report
Care records were incomplete
needs fixingSome care plans and risk assessments were not reviewed regularly, with missing or inaccurate information. Inspectors said people were receiving the right care at the time, but incomplete records could lead to inconsistent support.
“However, not all associated risk assessments had been frequently reviewed, and sometimes information was missing.” from the report
Staffing gaps
needs fixingThere were significant nursing vacancies and delays to checks for newly recruited nurses. Consistent agency staff were being used, but weekend staffing was sometimes reported to be poorer.
“There were significant nursing vacancies at the service, however a new experienced nursing team had been recruited” from the report
Support in bedrooms
needs fixingPeople who spent time in their rooms did not always have a drink or something to occupy them within reach. One bedroom was hot and some rooms were untidy.
“However, staff were not always vigilant in ensuring people had a drink in their reach or whether they had stimulation, such as the radio or television on.” from the report
Personal grooming
needs fixingSome people did not look as well groomed as they could have been. The provider was asked to consider this in dignity and respect training.
“Some people looked well dressed, whilst others did not.” from the report
Governance checks
needs fixingThere was no care plan audit at the inspection, so the management checks did not yet identify all documentation problems promptly.
“There were a variety of audits in place to monitor different aspects of the service such as the environment, however there was no care plan audit currently being used.” from the report
- 01How have you filled the nursing vacancies, and what is the current staffing position at weekends?
- 02How do you check that every person's care plan and risk assessment is reviewed and kept accurate?
- 03How do staff make sure people spending time in their rooms have drinks, comfort and suitable activities within reach?
- 04What changes have been made to support personal grooming and dignity?
- 05Have you introduced a care plan audit and improved documents for people who need information in an accessible format?
This was an unannounced inspection covering all five CQC questions, the premises and the care provided; the previous overall rating was Requires improvement. This explanation was written from the published report of 29 June 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2018
Butterfly Lodge was rated Requires Improvement overall, with serious weaknesses in leadership and problems with staffing, medicines, dignity and care records.
This was an unannounced comprehensive inspection on 1 and 2 October 2018. Inspectors spoke with people, relatives, staff and health professionals. They observed care and reviewed care records, staff files, training records and quality checks.
The home was rated Requires Improvement for Safe, Effective, Caring and Responsive. It was rated Inadequate for Well-led. Inspectors found risks were not always recorded accurately, staffing levels were sometimes below the home's own guidance, and medicines records were not always correct.
People were often treated with kindness, and families gave positive feedback. However, inspectors found that people's dignity, independence and social needs were not always supported. The home's checks did not identify important problems, and three regulations were breached.
Some improvements had been made since the October 2017 inspection. Recruitment checks were safer, accident trends were reviewed, and a new manager was preparing to take over. However, the overall rating remained Requires Improvement because further problems had been found.
Kind staff
People, relatives and an external professional described staff as kind and caring. Inspectors saw staff remain calm and take time to speak with people, even when staffing was reduced.
“People approached staff without hesitation.” from the report
Safer recruitment
The home had improved its recruitment checks since the previous inspection. These included employment histories, references and DBS checks, with a new system for checking recruitment files.
“The provider followed their recruitment policy and undertook relevant checks of all new staff.” from the report
Health professional involvement
People received pre-assessments before moving in and staff worked with external health and social care professionals to monitor people's needs.
“People's records indicated that staff worked collaboratively with external healthcare professionals to help ensure people's ongoing health care needs were monitored and met.” from the report
End-of-life care
Care plans recorded people's end-of-life wishes. Staff had palliative care training, and pain relief and end-of-life medicines were discussed with external professionals.
“People were supported with dignity, at the end of their life.” from the report
Learning from accidents
The home reviewed accidents and looked for patterns. This led to extra evening staffing after falls had been identified as more likely at that time.
“People's accidents were reviewed, and themes and trends analysed so action could be taken to help minimise reoccurrences.” from the report
Staffing shortages
seriousOn the first inspection day there were three care staff when the home's guidance said there should have been seven. This contributed to late medicines and people waiting until 12.30pm to get out of bed.
“The impact of this staffing deficiency meant that people's medicines were administered late, and people were assisted out of bed until 12.30pm.” from the report
Medicines records
seriousMedicine administration records did not always show when medicines were given at different times. Creams and other topical medicines were not always dated when opened, and pain relief was not properly reviewed.
“People's medicine administration records (MARs) were completed, but not always accurate.” from the report
Nutrition risks
seriousOne person's specialist diet was recorded inconsistently, and kitchen staff prepared the wrong type of food. Staff were not aware of the speech and language therapist's advice.
“The kitchen staff were preparing the wrong type of food, and staff were also not aware of the SALT advice which had been given.” from the report
Dignity and independence
seriousInspectors found examples of people being exposed, having personal items on display and not receiving enough help with personal presentation. Staff said they did not always have time to promote independence.
“People were not always treated with dignity and respect, and their independence was not always promoted.” from the report
Limited activities
needs fixingActivities were provided during the week, but staff said engagement was limited at weekends. Some people were left sitting alone or were not encouraged to join activities.
“There is less stimulation at the weekends” from the report
Weak quality checks
seriousThe provider had several audits, but they failed to find the problems identified during the inspection. The provider's visits were not recorded well enough and did not produce clear action plans.
“The providers governance framework continued to not be effective in helping to monitor the quality, safety and culture of the service.” from the report
- 01What staffing levels are now in place on each shift, and how do you cover sickness and vacancies?
- 02How do you now check that medicines are given at the prescribed times and that topical medicines are dated when opened?
- 03How are specialist diets and advice from speech and language therapists recorded and shared with kitchen and care staff?
- 04What has changed to make sure people receive enough personal care, dignity and support to remain independent?
- 05How do you monitor activities and social contact at weekends, particularly for people living with dementia?
This was an unannounced comprehensive inspection covering all five key questions, with the previous ratings also considered. This explanation was written from the published report of 24 November 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Butterfly Lodge
4 rated inspections over 3 years: the service has held its Good rating throughout.
- June 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 6 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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