Buttercup Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated good. This meant people were safe and protected from avoidable harm.
 

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Accidents and incidents were not always recorded in enough detail to ensure they were properly escalated. Monitoring systems were not effective in making sure lessons were learned or that good practices were embedded.

While incidents were analysed, important factors, such as which staff were involved, environmental triggers, or whether behaviour support plans [BSPs] were followed were not consistently considered.

Although staff told us they felt safe to raise concerns, and these were taken seriously when reported, safety processes overall were not reliable.
 

Safe systems of care were established and maintained in partnership with people and healthcare professionals. Continuity of care was ensured, including during transitions between services. Processes were in place to support smooth moves, reducing disruption for individuals. People were listened to and supported to move where they chose.

When hospital visits were needed, support was provided, including hospital passports to share essential health information. The manager worked with others to solve problems and make improvements. Regular contact was maintained with local authority social workers, GPs, and other professionals. Staff said they could reach health professionals when needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Safeguarding systems were established and understood. Staff had good understanding of safeguarding procedures and were able to describe how to recognise and respond to signs of abuse, demonstrating awareness of their responsibilities.

The manager understood their responsibilities to report any concerns promptly to the relevant external agencies. Records showed that concerns had been investigated, and safeguarding had been discussed with the staff team to embed knowledge of safeguarding for both adults and children.
 

The provider worked with people to understand and manage risks by thinking holistically. Risks associated with people’s individual care and treatment needs had been assessed and were regularly reviewed. Care plans had comprehensive risk assessments and corresponding care plans, so staff knew what action to take to reduce any risk of harm. Behavioural tools were in place to help staff minimise behaviour that communicates a need, emotion or distress, and how to respond safely and consistently. Staff were not consistently monitored to ensure they were following guidance in line with people’s needs as detailed in the well led section of this report.

Staff were clear about their responsibilities regarding premises and equipment. They used equipment correctly and supported people to stay safe.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People told us the physical environment did not effectively and consistently meet their needs, and the provider had acknowledged this and was taking proactive measures to support people to move between settings to maximise their independence.Staff were clear about their responsibilities regarding premises and equipment. They used equipment correctly and supported people safely. Safety audits and checks were completed regularly on the environment, premises and equipment. Fire risks were assessed, however staff had not consistently participated in regular fire drills to promote safe evacuation.
 

The provider ensured there were enough qualified, skilled, and experienced staff to meet basic care needs safely. However, staffing arrangements had not always been effective in supporting people to take part in activities they enjoyed. Limited availability of staff who were able to drive meant people could not always access the community as planned, which impacted their overall experience and independence.

While systems were in place for safe recruitment and deployment, we observed that some staff communication with people needed improvement. Information shared was not always accurate or up to date. For example, during our visit, we saw people being told certain staff were coming on shift when this was not the case. This caused confusion and did not support a reliable or person-centred approach.

Staff continued to receive relevant training, including in autism, learning disabilities, first aid, and moving and handling. Supervisions and appraisals were held regularly to support staff development, but further improvements were needed in communication and activity planning to ensure care was consistently responsive and engaging.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean and hygienic. An infection control policy was in place. Infection audits were being carried out to ensure the risks of infection was minimised. Staff had been trained in infection control. We observed the home was cleaned regularly with a cleaning schedule in place. Handwash facilities and personal protective equipment was available to minimise the risk of infections. We saw there was good food and hygiene procedures in place that was being followed by all staff.

Medicines were not consistently managed safely. Although protocols for 'when required' (PRN) medicines were available, they lacked detail, and reasons for administration and outcomes were not always recorded. PRN medicines used to manage people’s distress behaviour must be clearly justified, but records did not show this, in line with best practice. This made it unclear what actions were taken before medicines were given.

A medicines policy was in place. Staff were trained and assessed as competent to manage medicines. Following the inspection, PRN protocols were strengthened. Information about STOMP (Stopping Over-Medication of People with a Learning Disability or Autism) was available, and medicines reviews had recently been carried out. People were involved in planning their medicines and treatment, including during changes.