CQC report explained · a residential care home
What the CQC found at Butts Croft House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing, safeguarding and infection control were generally satisfactory, and medicines management had improved. However, there was no diabetes risk plan for one person, patch medicines were not always rotated correctly, one person's eye drops were past their use-by date, and accident analysis was not robust.
- Effective?
- Requires improvement
- Staff had the training needed and people received appropriate nutritional and healthcare support. Mental capacity assessments were not always completed effectively, and care plans did not specifically describe people's oral health needs.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Relatives and professionals described a warm, friendly atmosphere and staff who supported people's choices.
- Responsive?
- Good
- Staff responded to people's individual needs and preferences, and care plans were reviewed when needs changed. Activities were available and being expanded, although some personal information and end of life preferences were not always recorded in enough detail.
- Well-led?
- Requires improvement
- Management changes and new audits had improved medicines, infection control and administrative practices. However, quality systems were not yet fully embedded, with continuing gaps in risk management, care planning, records, accident oversight and staff practice reviews.
What inspectors found, May 2022
Rated Requires Improvement; inspectors found kind and responsive care, but records, risk checks and management systems were not yet reliable enough.
This was a follow-up inspection on 6 and 11 April 2022. The first day was unannounced. Inspectors spoke with people, relatives, staff and a healthcare professional. They reviewed care, medicines, staffing, incident records, recruitment files and management checks.
The home had improved its medicines systems, infection control and management arrangements. There were enough staff to meet people's needs safely. People were treated with kindness and respect, and relatives described a friendly atmosphere. Activities were being developed and care was generally personalised.
However, some important records and checks were still incomplete or inconsistent. These included a diabetes risk plan, mental capacity assessments, oral health and end of life care plans, food and fluid records, and analysis of accidents. One person's eye drops were used beyond their use-by date, although staff removed them immediately when this was identified.
The overall rating means the home was not consistently meeting the standards needed for a Good rating. It was no longer in breach of the regulations breached at the previous inspection, but it had been rated Requires Improvement for seven consecutive inspections. CQC said it would continue to monitor progress.
Kind and respectful care
Inspectors found that staff promoted a homely environment and maintained people's privacy and dignity. Relatives described staff as friendly, attentive and respectful.
“People's privacy and dignity was maintained, and staff treated people with respect.” from the report
Enough staff
Inspectors found there were enough staff to keep people safe and meet their needs. The provider had also recruited more permanent staff to improve consistency.
“There were enough staff to ensure people's needs were met safely.” from the report
Improved medicines and infection control
The home had improved how it ordered, administered and recorded medicines. Inspectors were also assured about its infection prevention and control arrangements.
“New systems introduced had brought about improvements in the management of medicines, infection control and the administrative practices of the home.” from the report
Good food and healthcare support
Staff understood people's nutritional needs, and snacks and drinks were available between meals. The home routinely sought and followed medical advice.
“Medical advice was routinely sought and followed.” from the report
Activities and personal choice
People could join activities such as crafts, dominoes, music, karaoke and bingo, while staff respected those who preferred their own company. Relatives could also share views about care.
“During our inspection visits we saw people joining in craft activities, a game of dominoes and listening to music.” from the report
Incomplete risk records
seriousOne person did not have a diabetes risk plan. Inspectors said this increased the risk of ill-health because staff did not have clear written guidance.
“Without clear records to direct staff on how to identify concerns relating to safe diabetes practices, there was increased risk of ill-health.” from the report
Medicines checks still needed improvement
seriousPatch medicines were not always rotated as instructed, and one person's eye drops were used beyond their use-by date. Staff took immediate action when the eye drops were found.
“We did identify one person's eye drops were being administered past their use by date.” from the report
Gaps in care planning and monitoring
needs fixingCare plans did not always cover oral health or end of life preferences. Food and fluid records were not consistently completed, which made it harder to check that people had received enough.
“This included people's food and fluid intake records which were not consistently completed to show people had received enough food and fluids to maintain their health.” from the report
- 01Has the diabetes risk management plan identified in the report now been completed and reviewed?
- 02How do you check that medicines, including patches and eye drops, are within date and administered according to instructions?
- 03Have all residents had the required mental capacity assessments, with records showing how they were supported to make decisions?
- 04How are food and fluid records checked to make sure they are complete and show that people are eating and drinking enough?
- 05What changes have been made to care plans for oral health and end of life preferences?
This was a follow-up inspection covering the overall service, with infection prevention and control specifically examined under the Safe key question. This explanation was written from the published report of 17 May 2022 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 2021
Rated Requires Improvement overall; inspectors found unsafe risk and medicines systems, and rated leadership Inadequate.
This was an unannounced focused inspection on 7 October 2021. Inspectors looked at Safe and Well-led, because of concerns about risks, medicines and management. They spoke with managers, staff, relatives and a healthcare professional, and checked care, medicines and management records.
The home had enough staff to meet people's needs, and relatives generally spoke positively about the care and staff. However, some risks were not properly assessed or recorded. Medicines records contained discrepancies, and inspectors could not be sure that medicines had always been given as prescribed. Infection control practice also needed improvement.
The home was rated Requires Improvement for Safe and Inadequate for Well-led. The overall rating was Requires Improvement. The other key question ratings were not inspected at this visit and previous ratings were used in calculating the overall rating.
The same two legal breaches found at the previous inspection continued. The home had been rated Requires Improvement at the last six consecutive inspections. The provider started an action plan and was recruiting a business manager to support quality checks.
Enough staff
Inspectors found enough staff on duty to meet people's needs safely, although vacancies meant the home used more agency staff.
“There were enough staff on duty to ensure people's needs were met safely.” from the report
Positive care feedback
People's relatives were generally positive about the care, staff and managers. They said staff were caring, attentive and approachable.
“Despite our findings people and relatives were satisfied with the service provided and spoke positively about the registered manager and the person centred care” from the report
Safeguarding awareness
Staff understood how to report concerns about abuse or unsafe practice. The manager understood their duty to report possible abuse to the local authority.
“Staff were knowledgeable about safeguarding and could explain the processes to follow if they had concerns.” from the report
Some environmental improvements
Inspectors saw that some improvements had been made to the physical environment to make it more stimulating and interesting for people.
“The management team showed us improvements made to areas of the physical environment to make it more stimulating and interesting for people.” from the report
Risks were not fully assessed
seriousSome people's risk assessments and care plans were incomplete or out of date. Guidance was missing for moving and transferring, choking, skin damage and nutrition.
“Some risks were not always identified, assessed and managed effectively and gaps in risk assessment tools in some care plans meant it was not clear how the level of risk had been assessed” from the report
Medicines records were unreliable
seriousInspectors found discrepancies in all three medicines records they checked. Records did not always show when medicines should be given, or match the stock held.
“People were at risk of not receiving their medicines as prescribed.” from the report
Infection control was inconsistent
needs fixingStaff did not always use masks, gloves and aprons in line with current guidance. The home also did not have a completed COVID-19 outbreak contingency plan.
“Staff did not consistently follow current guidance when using PPE, such as gloves, masks and aprons.” from the report
Poor management oversight
seriousAudits and checks had not found or fixed repeated problems. Medicines audits had not been completed since May 2021, and care record checks were ineffective.
“Audits were either not effective or had not been carried out which meant shortfalls in service provision had not been identified.” from the report
- 01How are you now checking that each person's risks, including choking, moving and transferring, skin damage and nutrition, are assessed and kept up to date?
- 02How do you now prove that medicines are given on the correct day and in the prescribed amount?
- 03What action has been taken to make sure medicine audits and care record checks are completed and acted on?
- 04What is the home's current plan for managing a COVID-19 outbreak, and how do you check staff follow PPE and testing guidance?
- 05Has the new business manager been appointed, and how is the provider checking that improvements are sustained?
This was a focused inspection of Safe and Well-led only; the other key questions were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 12 November 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.
Every inspection of Butts Croft House
7 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- May 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Inadequate
- November 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 18 February 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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