- Homecare service
Butterflies Care & Support Ltd
We served 2 warning notices on Butterflies Care & Support Ltd on 11 June 2026 for failing to meet the regulations related to safe care and treatment and good governance at Butterflies Care & Support Ltd.
Assessment report published 29 June 2026
Contents
Ratings
Our view of the service
Date of inspection: 6 May to 8 June 2026. Site visit was 11 May 2026. Butterflies Care Support Ltd is a care at home service providing support to adults of all ages, including those who are living with dementia care, physical disabilities, autistic people and people with a learning disability. At the time of the inspection there were 6 people being supported with the regulated activity of Personal Care.
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.
At this inspection, we found 3 breaches of regulation regarding safe management of risks and medicines, quality assurance systems and staff support and development.
Systems to ensure safe, effective and high-quality care were not in place or not used consistently. There was no effective oversight of the service by the provider and registered managers. The registered managers did not have effective processes to monitor risk or staff performance. Audits were not in place and learning was not embedded. This meant risks were not always identified or reduced.
Care planning and risk assessment were not detailed enough to support staff awareness of people’s health conditions. Important information about risks were not always recorded or supported with clear guidance. Medicines were not always managed safely and concerns were not escalated to health professionals.
Safeguarding systems were not consistently applied and staff knowledge varied. Training, supervision and competency checks were not effective, which meant staff were not always fully supported to deliver safe care.
Staff did not always work well with other services. Important information about people’s care was not always shared clearly or in a timely way. People were not always given a clear way to raise concerns, and the provider could not show how they learned from feedback or made changes to improve the service. The provider was unable to demonstrate how outcomes for people were monitored, reviewed or improved over time. This meant there was no clear evidence that people’s care was regularly checked to make sure it was effective or that their quality of life was getting better.
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Despite these concerns, people and relatives gave positive feedback about staff. There were examples of caring and responsive support, and some effort to work with other professionals and improve care.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
Despite our findings during this inspection in relation to oversight and records, people’s experience was mostly positive and they described staff as kind and reliable. People told us they felt safe and well cared for. They valued having a small, consistent team of staff who knew them well and understood their routines and preferences. One relative told us, “We have had a few companies but I think I fell on my feet when Butterflies fetched their [staff] in. They are first class and make my life a lot easier.”
People and relatives were able to speak with us over the telephone. Where people struggled to hear they were supported by their relatives to relay the conversation.
People said staff treated them with dignity and respect, supported their independence and involved them in everyday decisions. Staff took time to listen and adapt care to meet people’s needs. People felt able to express their wishes and were supported to make choices about their care, meals and daily routines.
Relatives spoke positively about communication from staff and felt able to contact them if needed. They told us staff responded to concerns and were approachable. People also described staff as responsive, especially in urgent situations, and said they felt reassured knowing staff would take appropriate action.
However, people’s involvement in reviewing and planning their care was not always consistent. Some people were not clear about their care plans or how often these were reviewed. There were also gaps in how information was shared and recorded, which meant people’s experiences were not always reflected in care records.
People were supported with their day to day health needs such as nutrition and personal care. Staff provided flexible support and were willing to go beyond planned tasks to meet people’s requests. Despite this, there were missed opportunities to support people to improve their health and wellbeing or access additional services when needed.