We carried out a review of the data available to us about Butterfly Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Butterfly Lodge, you can give feedback on this service.
People’s experience of using this service:
Since our last inspection the service had a new manager in post. People, relatives and staff were complimentary of them and of the changes that had occurred since her appointment, including the culture. A new operations manager had been employed to ensure effective ongoing assessment and quality of the service. A ‘global’ audit was being used by the operations manager to keep on top of regulatory compliance within the service.
There was a new compliment of experienced nursing staff due to commence employment.
People told us they felt safe and received kind and respectful care. Staff were recruited safely and improved understanding of safeguarding procedures following the previous inspection.
People lived in an environment which had been assessed for its safety. People lived in a clean and odour free environment.
People now received their medicines safely and the management of risks associated with people’s care had improved. The accuracy of people’s documentation had improved, but the manager recognised their own limitations in completing this task and spoke of the positive impact that additional nursing staff would have.
People were supported by staff who had received training to meet their needs, and had their human rights respected. The provider was considering how to apply the Accessible Information Standard (AIS) design and delivery in the service.
People felt confident to complain, and complaints were seen positively and used to improve the service.
We recommend dignity and respect training considers the care of those who choose to spend time in their own rooms and about people’s personal care. In addition we recommend the provider considers the Accessible Information Standard (AIS) in respect of the production of polices and procedures and that the provider continues to strengthen their governance framework.
More information is in Detailed Findings below.
Rating at last inspection: Requires improvement (Report published 24 November 2018).
Why we inspected: This was a planned inspection.
Follow up: We will continue to monitor this service and plan to inspect in line with our reinspection schedule for those services rated Requires improvement.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Freshfields Nursing Home provides care for people who may require nursing care and for people who are living with dementia. The service provides care and accommodation for up to 38 people. On the day of the inspection 32 people lived in the home.
There was a manager in place, who was registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The registered manager was due to retire at the end of 2018, therefore the provider had been pro-active and already employed a new manager, who had been working alongside the current registered manager for the past four months, to help ensure a smooth transition. The new manager would be applying to be registered with the Commission shortly.
At our last inspection in October 2017 the overall rating for the service was Requires Improvement because the recruitment of staff was not always carried out safely, and records relating to people’s medicines were not always accurate. In addition, people’s records did not clearly detail how their human rights were being protected in line with the Mental Capacity Act (2005); and the providers systems, to monitor the quality of care people received were not robust, in identifying when improvements were needed. Whist some improvements had been made, we found additional areas requiring action. Therefore, the rating of Requires Improvement remained.
People were not always protected from risks associated with their care. People had risk assessments in place to help guide staff to deliver safe care in line with people’s individual needs. However, people’s risks assessments, relating to their nutrition were not always accurate to help ensure people received safe support. We asked the registered manager to take immediate action to ensure one person received the correct meals, that records were updated to ensure their accuracy and staff knowledge and awareness improved.
People were not always supported by suitable numbers of staff who knew how to meet their needs safely and effectively. The registered manager told us, that whilst they had good numbers of nursing staff, they had experienced a difficult time, with large numbers of care staff recently leaving. They explained, recruitment was ongoing and that three new members of staff had recently been appointed.
People’s medicines were not always managed safety. People’s medicine administration records (MARs) were completed, but not always accurate. People received topical medicines (creams, pastes or lotions). However, these were not always dated upon opening, which meant staff could have applied topical medicines, which were out of date. There was no system in place to help determine if people needed their pain relief and/or whether it was successfully working; this is good practice especially with people living with dementia and/or who find communication difficult.
Overall, people were protected from abuse. However, whilst staff received safeguarding training and had access to safeguarding polices, some staff were not fully aware of the local authorities’ involvement in the investigation of allegations of abuse. The registered manager told us they would speak to staff to refresh their knowledge.
Overall, people were kept safe from environmental risks. All equipment was serviced in line with manufactures guidelines, the fire system was checked on a weekly basis and underwent an annual review to ensure its continued safety. However, on both days of our inspection we found two doors propped open, because batteries in fire release door guards were not working. We also found a large number of wheelchairs, and three carpet cleaners stored in a designated fire escape. The assessment of these risks, had not been included within the providers fire risk assessment. Therefore, the provider told us immediate action would be taken.
People had care plans in place to help provide guidance and direction to staff about how they wanted to receive their care and support. However, staff told us they did not always have time to read them, and told us they just got to know people by watching a listening to see how other staff supported them.
People’s care plans were handwritten therefore consideration had not been given to whether they were in a suitable format for people and/or their loved ones to be able to understand. People’s communication needs were documented in their care plans, staff told us how they adapted their own communication styles to help people to understand them.
People’s continence needs were managed. People were reminded to go to the toilet discreetly and supported when required. Staff, however told us, that when there are staffing shortages, some people are not supported when they should be, resulting in them being uncomfortable or incontinent.
Despite positive feedback from relatives, people’s social needs were variably met, and people living with dementia did not always receive the time and support they needed from staff, to help positively distract or engage them.
Staff told us, they found it difficult to promote people’s independence because they did not always have time and/or the resources to be able to. Staff explained how they felt people’s care was task ordinated, rather than being person-centred and tailored to people’s individual social and emotional needs.
Overall, people’s privacy and dignity was promoted by staff, most staff knocked on people’s bedroom doors before entering, and when risk assessed, people could have their own lock and/or key. One person was wearing excessively large and loose trousers, which fell down whilst they were walking. This resulted in them exposing their incontinence pad and pants. Whilst, a member of staff at the time, pulled them back up, the situation wasn’t resolved.
People’s care plans now included a section regarding their mental capacity and how they should be suitably supported. Staff had undertaken training in the Mental Capacity Act (2005). However, despite staff receiving training, staff’s knowledge was limited about the deprivation of livery safeguard applications (DoLS). Staff were unaware of who had DoLS applications in place, and what this meant for people. This meant people’s human rights may not be suitably protected.
Overall, people received care and support from staff who had undertaken training, the provider had deemed to be mandatory. However, despite staff receiving training it was not always put into practice. For example, staff undertook privacy and dignity training, however we found improvements were required in this area.
People were supported to eat and drink, and offered drinks by staff at certain times of the day. However, records about people’s consumption, were not always detailed and/or accurate.
The dining experience did not fully support and enable people, living with dementia. The principles of good dementia care were not followed, for example people were all verbally asked what they wanted for lunch and not shown. People and their relatives told us they liked the food and the options which were available.
The registered manager and provider told us they had already recognised that action was needed to improve the dining experience for people. The provider had already sourced a new training course called dignity and dinning, and would be asking staff to attend.
People living with dementia, were not always fully supported by the decoration of the service. Areas of the home, such as people’s bedrooms, toilets and bathrooms were not always labelled with pictorial images to help ordinate people.
The registered manager had a variety of quality audits which formed the basis of the providers ‘global audit’. Audits were completed on a monthly and quarterly basis by the registered manager, and designated staff. However, despite these being in place, they had failed to identify the areas found to require improvement as part of this inspection.
Most staff told us they liked working at the service, but at times, felt that there was a poor culture which resulted in staffing indifferences, and task ordinated care provision
People were seen to comfortably approach and speak freely to staff, and families told us they felt their loved ones were “Safe”. Since our last inspection, the provider had installed closed circuit television (CCTV) in communal areas, to help ensure peoples ongoing safety.
People, at our last inspection in October 2017, were not protected by the provider’s own recruitment procedures, but at this inspection we found action had been taken to ensure people were fully protected. The provider had also introduced a new monitoring and checking system of recruitment procedures.
People were supported safely when mobilising, and wheelchairs were used appropriately with footplates. People’s accidents were reviewed, and themes and trends analysed so action could be taken to help minimise reoccurrences.
People lived in a service whereby the provider learnt when things had gone wrong and used the learning to help improve the service.
People were protected by infection control processes to help reduce the unnecessary spread of infection. Staff received infection control training and wore the required personal protective equipment (PPE), such as gloves and aprons, when assisting people with personal care.
People were supported with dignity, at the end of their life. Staff had received palliative care training. People had care plans in place to help staff know what their end of life wishes were. Pain management and end of life medicines were discussed with external pr
A manager was employed to manage the service who was registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People received their medicines on time from staff members who were trained to manage medicines safely. However, actions for improvement, identified in a medicines audit, had not all been implemented.
People’s healthcare needs were met but the care required to meet these needs was not always recorded consistently across people’s records and the care provided not always recorded.
Staff had a good understanding of how to support people who lacked the capacity to make their own decisions. However, records were not in place detailing how people’s capacity had been assessed. Following the inspection, the registered manager confirmed these records had been put in place.
Recruitment practices were in place but the career history of new staff members had not always been recorded in full, to help ensure they had the correct characteristics to work with vulnerable adults.
New members of staff completed an induction programme but records did not show how this had been tailored to ensure they received all the support they required at this time. Not all staff training was up to date. A senior manager told us they were working with the registered manager to ensure all required staff training was up to date.
Staff had not received as many formal supervisions as required by the provider’s policy. The registered manager explained they had now put systems in place to reduce the risk of this happening again.
Quality assurance systems were in place to monitor the quality of the service being delivered. However they had not identified all the gaps in quality identified during the inspection. Recent checks had not identified some windows and a gate did not have locks or restrictors on them. The registered manager told us learning and improvements had taken place as a result of this and they had reviewed security measures.
Relatives were positive about the service their family members received. Comments included, “I’m so pleased we chose for […] to live here. The atmosphere in the home is so positive and she tells me she’s very happy here”, “There’s nothing they can do better” and “I felt I was coming to a special place, which I was.”
People were treated with kindness and compassion in their day-to-day care. Staff were exceedingly caring and openly affectionate towards the people they were supporting. One staff member explained, “We aim to give the clients 100% dignity and respect, to be person centred and ensure they’re safe.”
Staff knew people well and used this knowledge to ensure people’s needs were met. One staff member told us, “People come first. People are our number one priority and giving each one person centred care. They’re like my grannies and grandads. That’s how I treat them.”
The registered manager and staff were keen to make people feel a part of the home. People were supported to make decisions and have as much control over their daily lives as possible. People and their relatives were involved in planning their own care and making decisions about how their needs were met. Care plans were in place that explained people’s needs and were reviewed regularly.
People’s friends and relatives were made to feel welcome at the service, consulted about their loved one’s care and preferences and treated compassionately when their family member was receiving end of life care.
Relatives felt Freshfields Nursing Home was a safe place for their family member to live. People were supported by staff who understood how to protect them from abuse and from risks relating to their care needs.
The registered manager knew people and their needs well, valued people’s feedback and acted on their suggestions. People’s concerns and complaints were encouraged, investigated and responded to in good time.
Staff were positive about how the service was run and told us they were happy in their work.
The environment had been planned with people living with dementia in mind. The service had good links with the local community.
The Inspection took place on 6 and 7 October 2015 and was unannounced.
Freshfields Nursing Home (referred to as Freshfields) is registered to provide accommodation, nursing and personal care to 38 people.
The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
During the previous inspection in June 2014 we asked the provider to take action to improve aspects of people’s care, the staffing levels, quality assurance processes and to inform CQC of important events that occurred at the home. The provider sent us an action plan informing us of the improvements that would be made in these areas. We found improvements had been made.
During the inspection people and staff were calm and relaxed; the environment was clean and clutter free. There was a happy, peaceful atmosphere. Comments from people, relatives and health professionals were very positive.
Care records were focused on people’s needs and wishes and encouraged people to maintain their independence. Staff responded quickly to changes in people’s needs. People and those who mattered to them were involved in identifying their needs and how they would like to be supported. People’s preferences were sought and respected. People’s life histories, disabilities and abilities were taken into account, communicated and recorded, so staff provided consistent personalised care, treatment and support.
People told us they felt safe and secure. People who were able to share their views told us they felt the home was safe. Staff described how they kept people safe through regular observation, maintaining their training and equipment checks. We saw staff were visible in the shared areas and responded promptly when people required assistance. Equipment to maintain people’s safety was visible where needed for example grab rails in bathrooms and accessible call bells.
Staff were kind, thoughtful and compassionate. People, relatives and professionals were exceptionally positive about the quality of care and support people received. Supportive, kind and respectful relationships had been built between people, family members, professionals and staff. Staff took pride in their roles and the care provided which made people feel special.
There was an open, transparent culture where learning and reflection was encouraged. People’s risks were monitored and managed well. Accidents and safeguarding concerns were managed promptly. There were quality assurance systems in place in all areas. Incidents related to people’s behaviour or well-being were appropriately recorded and analysed. Audits were conducted in all areas, action points noted and areas improved where needed. Feedback during the inspection was listened to and changes made immediately. Staff received good training and held lead roles in particular areas such as end of life care, infection control and dignity. Research was used to promote best practice in dementia and end of life care.
People were encouraged to live active lives and were supported to participate in community life where possible. Activities were meaningful and reflected people’s interests and individual hobbies for example bingo, dominoes, arts and crafts and group discussions. External activities and visits from school children were enjoyed. People were supported to maintain their spirituality.
People had their medicines managed safely. People received their medicines as prescribed, received them on time and understood what they were for where possible. Improvements to medicine management were made during the inspection to ensure everyone had clear plans in place to monitor all prescribed medicines and the temperature of medicines. People were supported to maintain good health through regular visits with healthcare professionals, such as GPs, dieticians and chiropodists.
People, friends, relatives and staff were encouraged to be involved in meetings held at the home and helped drive continuous improvements. Feedback we reviewed was excellent from families and health professionals. Complaints were investigated and responded to promptly. Listening to feedback helped ensure positive progress was made in the delivery of care and support provided by the home.
People and those who mattered to them told us the management team and staff listened and were approachable. People told us they did not have any current concerns but any previous, minor feedback given to staff had been dealt with promptly and satisfactorily. Staff described the management as open, very supportive and approachable. Staff talked positively about their jobs, understood their roles and felt valued.
Staff understood their role with regards to ensuring people’s human rights and legal rights were respected. For example, the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS) were understood by staff. All staff had undertaken training in safeguarding adults from abuse; they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. Staff told us they felt confident any incidents or allegations would be fully investigated.
Staff received a comprehensive induction programme and the Care Certificate had been implemented within the home. Sufficient staff were available to meet people’s needs. Staff were appropriately trained and had the correct skills to carry out their roles effectively. Training was used to enhance staff skills and the care people received.
People’s end of life wishes were known and specific details sought and recorded about how people wished to be cared for in their final days. Staff had completed the local hospice end of life care programme and acted as “champions” in this area.
As part of our inspection we spoke with five people who were able to share their views about the home with us and talked with six members of nursing and care staff and the Registered Manager. We spent long periods of time observing the care people received in the downstairs lounge and reviewed people's care records. We followed the care of one person since their admission. This meant we spoke with staff about their care, reviewed their care files and listened to the views of their relative. We also spoke with external health and social care professionals who referred people to the service and had visited recently. In addition, we reviewed the information we had received from the service about incidents which had occurred over the past six months.
We considered our inspection findings to answer the following five questions we always ask;
Is the service safe?
Is the service effective?
Is the service caring?
Is the service responsive?
Is the service well-led?
This is a summary of what we found.
Is the service safe?
People were treated with kindness, dignity and respect by staff. During our daytime visit on 6 June 2014 we saw staff responding promptly when people appeared unwell. The five people we spoke with who were able to share their views told us they felt safe at the home. Safeguarding training was in place, there were policies for staff to follow and the staff we spoke with were aware of the possible signs of abuse. We observed the interactions between staff and people who used the service, these were positive and we saw staff respected the people they were caring for. However, during our night time visit on June 5 2014 we were concerned there were not sufficient staff on duty to meet people's needs and this put people at risk. We observed long periods in the lounge where people were left unattended and were unable to call for help should they have needed support. We needed to call staff for help on several occasions to help keep people safe and although staff responded promptly we were worried for people's safety after 8pm when staffing levels were less but many people were awake requiring support and observation.
CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Registered Manager told us they had not needed to submit any applications. We saw that there were policies in place but these required reviewing following recent case law. From the conversations we had with the manager and staff we felt confident there was a good understanding of the processes which the home would need to follow to submit an application should one be required.
We found the home was safe, clean and hygienic with regular infection control audits occurring. We saw there were thorough checks of the home's equipment including hoists and fire alarms to ensure they were well maintained. We checked two pressure mattress settings for people and found these were on the correct setting for the person's weight.
Although there were a number of quality monitoring systems in place, we were concerned that analysis of some audits which had identified risk had not resulted in actions to reduce the risks for people at the home. Recent investigations which had occurred prior to our inspection and advice given from external agencies had not yet been implemented which meant people were at risk at certain times of the day.
Is the service effective?
People's health and social care needs were assessed and information gathered about people prior to their admission to ensure the home could meet people's individual needs. We found through our conversations with staff that they knew a lot about people's individual needs and risks, liaised closely with external agencies and made prompt referrals for specialist advice when needed. However, we found care plans did not always detail clearly how staff should care for people to reduce the risks. This meant care was not joined up for some people which placed them at risk.
The home had received the Dementia Quality Mark (a local quality initiative for care homes supporting people with dementia) and we saw a lot of good and developing practice evident in our observations. Staff spoke to people at their level, were sensitive to their non-verbal communication styles where people were not able to verbally communicate. There were many adaptions to the home to support people to move safely and eat well, for example handrails and coloured utensils.
Is the service caring?
Everyone we were able to speak with felt the staff at the home were kind and caring. We observed staff who were patient, gentle and spoke calmly with people to reassure them and encourage them to participate in activities and personal care interventions. We saw people felt comfortable around staff and smiled and laughed as they interacted with them. Staff spoke knowledgeably about people and in a manner which indicated they cared about the people they were looking after. Relatives we spoke with confirmed they felt the staff were caring.
Is the service responsive?
People told us 'It's going smoothly so far, I have been here ten years!'
We found the home was responsive to people's health needs and aware of changes to people's health. We heard in the staff handover how staff had requested a visit from people's doctors promptly when they were unwell. New prescriptions for people had been obtained quickly and referrals to external agencies such as the tissue viability nurse were made promptly where there was concern about people's skin condition.
One person we observed became unwell during our inspection. Staff responded immediately to the person and within minutes a nurse was present to take the person's observations. We found when we used the call bell staff came within minutes to assist people and people told us they rarely waited longer than five minutes when they used their call bell.
Is the service well-led?
People at the home spoke highly of the Registered Manager. We found the Registered Manager responsive during our inspection feedback, they listened and intended to make improvements where indicated.
The home had a quality assurance process in place. We were concerned that it was not always evident what action had been taken following concerns being identified and we were worried some of the concerns we found during our inspection had not been identified by the home's quality assurance processes.
We spoke with the registered manager and reviewed five care records in people's rooms. All care records we reviewed were accurately completed and reflected the care people were receiving.
We found the home had good systems in place to assess and monitor the quality of the service provided. These included reviewing any complaints made, a six monthly questionnaire which was sent to people and reviewing accidents and incidents on a monthly basis. The home acted promptly where action had been identified to improve the care people were receiving.
We found that people at Freshfields Nursing home had their views listened too and they were able to contribute to the home during the regular coffee mornings which were held and they were able to complete questionnaires about the service.
We found care was assessed according to people's individual needs. Risk assessments were completed and regularly reviewed and external health professionals were consulted about people's care where necessary. A quiet room was being created for people and improvements to the home had occurred to meet the needs of people with sensory difficulties. People had the opportunity to engage in activities with the activities co-ordinator or could choose to spend time in their room.
We found the home was clean and there were regular checks and audits completed about all aspects of the home and equipment. The staff we spoke with were well trained and felt supported in their roles. Staff were encouraged to develop their skills through further training and staff had recently completed training in end of life care.
The home had a complaints policy and people felt able to raise any concerns they might have.
We saw calm and sensitive interactions by the staff with the people using the service. We saw staff encouraging and prompting people to make decisions to enable them to maintain their independence. When people needed assistance we found staff worked alongside at a pace suited to the person.
We found one area of the home had bedrooms overlooked by neighbouring properties. These rooms had no screening protection in place to ensure people's dignity and privacy were maintained.
We found staff knew what to do if they were concerned someone was at risk and if they were concerned about anything in the home. They were confident they would take appropriate action if they felt it was needed.
We found appropriate arrangements were in place to ensure the safe use and management of medicines.
We found people were cared for and supported by suitably qualified, skilled and experienced staff. There were not however effective management systems to monitor volunteers working in the home.
We found the Care Quality Commission was not notified about incidents that affected the heath, welfare and safety of people using this service so that where needed action could be taken.
One person told us that they were able to have privacy when they wanted it and that staff listened to what they had to say. This person chose to spend time in their own room and staff respected this decision. Another person told us 'They look after us very well here'.
Activities were provided during the morning and we saw that people were able to take part or decline depending on their preference.
We heard people being offered choices during coffee time and the lunch time meal. People were given visual prompts which enabled them to choose lunchtime meals, puddings and drinks. When staff assisted people with procedures such as helping them to move, staff clearly explained what they were doing and obtained consent where possible.
One visitor told us that, because their relative was unable to make decisions for themselves, they were involved in their care on their behalf. They said that they were kept well informed, telling us, 'I am totally involved and get regular up-dates'
A relative told us, 'Staff understand Mum; they treat her so well'they listen to me and respond to her preferences and engage her'.
Visiting staff from social services told us about the good working relationship they had with the home and remarked on the good progress made by one person recently admitted to the home. Overall they were very happy with the care provided to people.