CQC report explained · a residential care home
What the CQC found at Butterley House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2021
Rated Good overall, but inspectors found the home’s leadership and quality systems still required improvement after a previous Inadequate rating.
Inspectors visited without warning on 5 January 2021. They spoke with staff, relatives and health professionals, reviewed care and medicines records, checked staff files and examined the home’s management records. They also checked infection control arrangements.
People were found to be safe, supported by enough staff and given their medicines correctly. Care was personalised, people were treated kindly and with dignity, and care plans reflected their needs and choices. The home had improved its environment, including signage, bedrooms, communal areas and a visiting pod.
The home was rated Good for Safe, Effective, Caring and Responsive. Well-led was rated Requires Improvement because improvements had not yet been shown to be fully sustained, and relatives said communication about COVID-19 guidance and developments could be better.
The previous inspection, published in August 2020, rated the home Inadequate and found multiple breaches. This inspection found enough improvement for the home to no longer be in breach of regulations, but CQC said it would continue to monitor the service.
Personalised care
People received individualised care in a homely setting. Staff knew people's preferences and supported them to make everyday choices.
“People received personalised care in a homely environment.” from the report
Safe care
Risk assessments were in place and medicines records were accurate. Staff understood safeguarding procedures and there were enough staff for the current number of people.
“People had received risk assessments to ensure any areas of concern had been mitigated.” from the report
Kind and respectful staff
Inspectors saw positive interactions, with staff considering people's comfort, interests and preferences.
“We observed people being supported and this reflected positive interactions with people from staff who knew them well.” from the report
Improved environment
The home had made changes to make it easier for people to use, including clearer signage, refurbished spaces and a walk-in shower.
“The provider had made improvements.” from the report
Contact with relatives
The home used technology and a visiting pod to help people maintain relationships during the COVID-19 period.
“People had been encouraged to keep in contact with relatives and people of importance through a range of methods.” from the report
Improvements not yet fully established
needs fixingThe provider had made many changes, but CQC was not yet confident that they would continue over time. This is why the well-led rating remained Requires Improvement.
“The provider had made many improvements however some were not yet fully embedded to provide us with assurances to support sustainability.” from the report
Communication with relatives
needs fixingRelatives said communication could be better, particularly about new COVID-19 guidance and ongoing developments at the home.
“Relatives we spoke with felt that improvements had been made. However, they had all identified that communication could be improved in sharing any new guidance around COVID 19 or ongoing developments within the home.” from the report
Further end of life training
minorStaff had some online training but many wanted more training in end of life care. The provider said it would review this.
“Staff had received some online training in this area, many we spoke with expressed a wish to have further training.” from the report
Visiting pod sound
minorOne relative said the visiting pod needed a microphone because it was difficult to hear. The provider said it would address this.
“I have used the visiting pod, although it does need a microphone system as we had to mime.” from the report
- 01How are you checking that the recent improvements remain in place over time?
- 02How will you keep relatives informed about COVID-19 guidance and other developments at the home?
- 03What further end of life training will staff receive, and when?
- 04Has the microphone system for the visiting pod now been installed?
- 05How are activities organised when there is no dedicated activities staff?
This planned inspection covered all five CQC key questions and included infection prevention and control checks; it followed the previous Inadequate inspection published on 27 August 2020. This explanation was written from the published report of 30 January 2021 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, August 2020
Rated Inadequate and still in special measures; inspectors found serious risks in care, safeguarding and management.
This was a focused inspection on 23 July 2020. Inspectors looked at whether the home was safe and well-led. They spoke with people’s relatives, staff and professionals, observed care, and checked care records, medicines records, staff records and management audits.
The home was rated Inadequate for Safe and Well-led. People were at risk because repositioning, diabetes care, hydration, falls management and medicines procedures were not reliably managed. Two incidents, involving a head injury and choking, had not been reported to the CQC or local authority.
Inspectors found that audits and incident records were not being used properly to reduce risks. Staff did not always have the right training or skills, and some staff felt concerns were not listened to. Infection control, cleaning, protective equipment and staff recruitment checks were areas that worked better.
The home had also been rated Inadequate at the previous inspection, published on 14 February 2020. Inspectors found that not enough improvement had been made, so the home remained in special measures.
Infection control
Inspectors found that the home was clean and that staff had the protective equipment needed during the COVID-19 pandemic.
“The home was clean, and measures were in place to ensure continued daily cleaning to reduce the risks.” from the report
Staffing levels
There were enough staff for the number of people living at the home at the time of the inspection.
“There was enough staff to meet the current occupancy of the home.” from the report
Recruitment checks
The recruitment records checked showed that references and police checks had been completed before staff started work.
“The required checks had been completed which included references and a police check before commencing their role.” from the report
Working with professionals
The provider worked with health and social care professionals and the local infection control lead on environmental improvements.
“The provider had also worked with the local infection control lead to consider measures to improve the daily environment in reducing the risk of infection.” from the report
Risks to people’s health
seriousPeople were not always repositioned as required, and some people did not receive the right diabetes meals or enough fluids. Staff lacked training and guidance in some of these areas.
“This lack of training and guidance for staff, put people at risk of diabetic needs being responded to unsafely.” from the report
Safeguarding and incident reporting
seriousTwo incidents involving a head injury and choking had not been reported. The home had also failed to learn effectively from safeguarding investigations and repeated falls.
“We found two incidents which had occurred had not been reported to us or the local authority.” from the report
Medicines management
seriousSome medicine records were handwritten without a checking process, and staff did not have clear guidance about medicines given when needed.
“There was no process for checking that handwritten records were accurately recorded.” from the report
Weak management oversight
needs fixingAudits were inconsistent and had not driven improvements. A weekly medicines audit had not been completed for three weeks.
“A weekly medicine audit had not occurred for the last three weeks.” from the report
Open communication
needs fixingSome staff felt they were not listened to, and relatives did not always receive regular updates about their relative’s day-to-day care.
“One relative said, "You only get to hear when things have gone wrong, not the good stuff.” from the report
- 01What specific changes have been made to ensure people are repositioned on time and pressure damage risks are recorded and checked?
- 02How are diabetes meals, blood sugar risks and hydration needs now recorded, communicated to staff and monitored?
- 03What checks are now in place for handwritten medicines records and medicines prescribed to be given when needed?
- 04How are falls, choking, injuries and other incidents reported, investigated and used to prevent similar harm?
- 05What evidence can you show that staff concerns are now heard and that relatives receive regular updates about their relative’s care?
This was a focused inspection of Safe and Well-led only; the other three ratings were carried over from previous comprehensive inspections. This explanation was written from the published report of 29 August 2020 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.
Every inspection of Butterley House
3 rated inspections over a year: the service has improved, from Inadequate to Good.
- January 2021Goodcurrent ratingup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2020Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- February 2020InadequateSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- January 2019
Registered with the Care Quality Commission on 23 January 2019.
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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