Buttercup Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to shortfalls in governance, leadership and quality monitoring.
 

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy, and culture focused on transparency, equity, inclusion, human rights, and respect for diversity. Leaders at all levels understood the needs of the people they supported and operated in line with the culture and values of the workforce and the organisation.

However, while these systems, values, and strategies were in place, staff had not always followed them consistently. The provider had recently recognised the potential for a closed culture among the staff team. In response, the provider took action to address this concern by introducing an interim senior management team to help guide the service and ensure alignment with the provider's values.

The provider had clear systems and values in place, however they needed strengthening and embedding into practice.
 

At the time of the inspection, there was no registered manager in post, leading to inconsistent leadership, gaps in service delivery, and weakened oversight. The provider was supporting people with a learning disability without having the correct service user band registered with the CQC. This failure, which was not identified by the provider’s governance systems, resulted in a breach of legal regulations related to governance and oversight.

The provider was aware of the "Right Support, Right Care, Right Culture" guidance, which emphasises person-centred care for people with learning disabilities and autistic people. However, the provider had not fully ensured that these principles were consistently applied across the service.

The acting manager, supported by a deputy, demonstrated the necessary skills and knowledge to lead improvements and had begun the process of applying to become the registered manager. They were receptive to feedback and took immediate action to address the issues identified during the inspection.

The provider had appointed a nominated individual (NI) who was responsible for the overall management of the serviceand ensuring compliance with regulatory requirements. The NI joined the management team and demonstrated, through their knowledge, that they could guide the strategic direction of the service. Staff felt supported, and the acting manager showed a strong commitment to driving improvements.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
Staff took part in regular team meetings and supervision sessions. They told us they felt supported and understood their responsibility to report concerns. One staff member said, “I have supervisions and feel listened to by the manager.”

The service had a clear whistleblowing policy, and staff were aware of how to use it. Staff were supported with training and development, which helped them build their knowledge and skills. Policies were also in place to promote equality and diversity.

Staff were supported in their roles, understood how to raise concerns, and had access to development opportunities.
 

All staff had been supported with their professional development. Staff had received robust training and opportunities to develop their knowledge and skills.
Policies and procedures were in place to promote equality and diversity.

Staff were included in the running of the service and told us they felt involved in decisions that affected their work. Regular communication and team meetings gave staff the opportunity to share ideas, raise concerns, and contribute to improvements.
 

The provider’s systems had not identified or addressed key issues, including problems with medicines management, health monitoring, behaviour support plans (BSPs), and fire safety. This showed that existing monitoring processes were not fully effective.

A new leadership team was in place; however, systems and processes to monitor the quality and safety of the service needed strengthening and embedding into daily practice.

During the inspection, the provider and senior management team were open and honest, and they shared all the information we requested.

While the leadership team was responsive and transparent, weaknesses in oversight meant risks to people’s safety had not been identified or acted on promptly. Improvements in governance were needed to ensure safe and consistent care.
 

The provider worked in partnership with others to help ensure people received joined-up care that met their needs. They shared information and learning with health and social care professionals and collaborated to support continuous improvement.

Staff worked closely with professionals such as social workers, occupational therapists, and GPs to respond to people’s changing needs. Care plans showed evidence of this input, and staff used the guidance provided to support people effectively.

The management team also involved people, their families, and staff in decisions about care and service development. Relatives told us they felt involved and consulted.

Overall, the provider demonstrated a clear commitment to partnership working, and had plans which would support improvement for people’s and ensure care was coordinated across different services.
 

There had been some issues with management, which meant that the provider had not always focused on making improvements or being innovative across the organisation. However, the management team shared their plans to make things better by focusing more on fairness, positive outcomes, and improving the quality of life for everyone.
They regularly asked for feedback from people, families, and staff, who said they felt involved in meetings and discussions. There was also work being done to improve how records were kept, supporting learning and development. When concerns were raised, they were handled carefully and privately, with lessons shared to ensure things kept getting better.
The goal was to create a more stable environment by making leadership more consistent, which would help the service meet the right standards and improve care for everyone. This approach also supported the Right Support, Right Care, Right Culture (RSRCRC) values, ensuring people receive right care in the right way.