You are here

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 29 August 2020

About the service

Butterley House is a residential care home providing personal care to 23 people aged 65 and over at the time of the inspection. The service can support up to 37 people.

The accommodation is provided over two floors. The upper floor has bedrooms, toileting and bathing facilities. The downstairs also has bedrooms and toilet and bathing facilities with the addition of communal spaces, a conservatory and a dining space.

People’s experience of using this service and what we found

The provider had not always provided us with assurances in relation to the governance of the home. There were insufficient systems in place to monitor the care and ensure people were safe from harm or risks mitigated.

Audits had not always been completed or used to develop improvements. Staff did not feel there was an open culture in the day to day running of the home or their concerns were addressed.

The systems in place to have oversight of staff training, medicines management and risk to people were not thorough enough to manage and improve the service. We found risk to people in relation to pressure care and falls management. We also found staff lacked the training and skills to support people in these and other areas of care.

Information about people’s dietary needs had not been shared and this placed people at risk of receiving a meal unsuitable for their needs. Care plans and risk assessments associated with dietary needs had not been completed

Opportunities to learn from incidents had not been followed and we saw this had impacted on the risk in relation to safeguarding and keeping people safe from harm.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Relatives felt they had been provided with information about the pandemic, however they were not always kept informed of day to day events about their relative.

Partnerships which had been established were now being used to affect environmental changes. Infection control was managed well, and the staff were following recent guidance.

Staff recruited to work in the home had received the required checks in relation to references and a police check. There was enough staff to meet the current occupancy of the home.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The rating at the last inspection was inadequate (published 14 February 2020)

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, not enough improvement had been made and the provider was still in breach of regulations. The service remains in special measures.

Why we inspected

We received concerns in relation to the management of medicines, infection control and governance in the home. We reviewed the information we held about the service. We completed a risk assessment relating to the COVID-19 pandemic that was ongoing at the time this inspection was completed. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. Ratings from previous comprehensive inspections for the other key questions were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Butterley House on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and discharge our regulatory enforcement functions re

Inspection areas



Updated 29 August 2020

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 29 August 2020


Requires improvement

Updated 29 August 2020



Updated 29 August 2020



Updated 29 August 2020

The service was not well-led.

Details are in our well-led findings below.