During an assessment under our new approach
We visited the service on the 7 May and 12 May 2025.
Buttercup Lodge is a residential care home, providing support to younger adults, children and people with mental health conditions. At the time of our inspection 2 people were using the service. Our inspection was prompted due to the service not yet being rated.
We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.
Support was not reliably provided in line with people’s individual needs and preferences. Structured activities were lacking, leading to visible distress during observations. Monitoring of health conditions was inconsistent, and staff did not always act promptly on changes, though healthcare access was facilitated. Communication tools outlined in care plans were not always used, contributing to avoidable confusion and distress. Behaviour support plans were not consistently followed or reviewed, and analysis of incidents lacked detail to ensure meaningful learning. Records did not always justify the use of restrictive practices. Safeguarding practices were in place and staff and the manager were aware of how to respond and report concerns.
Oversight systems failed to identify several shortfalls, and governance processes were not sufficiently robust. Feedback from relatives was mixed, and access to meaningful activities was limited by staffing capacity, including a lack of available drivers.
However, staff were kind, caring, and treated people with dignity and respect. The environment was clean and safe, with good infection control practices in place. Staff felt supported and had received training relevant to their roles. Leadership had recently improved following changes to the management team, and steps had been taken to address identified issues.
The provider failed to consistently meet the expectations of the Right support, right care, right culture guidance. Care was not always person-centred, and the service was found to be in breach of regulations relating to person-centred care and good governance.
An action plan has been requested from the provider to address the breaches and concerns identified during this assessment.