- Care home
Butterley House
We served a warning notice against First For Care Limited Ltd for failing to implement effective governance systems to oversee risk and quality, which placed people at risk of harm at Butterley House Care Home.
Assessment report published 10 September 2026
Contents
Ratings
Our view of the service
Date of assessment: Wednesday 15th July 2026 – Thursday 23rd July. Butterley House is a residential care home providing personal and nursing care to 34 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, toilet and bathing facilities. The downstairs also has bedrooms and toilet and bathing facilities with the addition of communal spaces, a conservatory, a lounge and a dining space.
We previously inspected Butterley House in November 2025, where the provider was rated requires improvement for the key questions of safe and well led, and found to be in breach of the legal regulation relating to safe care and treatment. The provider sent us an action plan following this and addressed the concerns we identified. . Whilst we found improvements with regards to safe care and treatment, Governance continued to be a concern.
The provider did not have effective governance systems in place to ensure the quality and continuity of care, and there was a lack of learning and analysis from accidents and incidents. The provider did not always keep accurate records, with fluid charts containing inaccurate information about people’s level of fluid intake. We were not assured the provider had effective systems of governance in place to keep people safe. The concerns relating to a lack of effective governance were identified during our previous inspection in November 2025 and the provider had not made improvements in this area. As a result of these concerns, the provider was found to be in breach of the legal regulation relating to governance.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.
We found there had been improvements in the quality of care plans and risk assessments. Care plans were now detailed and reflected people’s care needs and risks. The provider ensured there were enough trained staff on shift to keep people safe. Staff were approachable, caring and had a good rapport with people. The care home was clean and tidy. Fresh meals were prepared and catered for people’s dietary requirements.
People's experience of this service
Several relatives expressed concerns about a lack of stable leadership with management changing regularly, and a lack of communication from the home regarding their family member. Other concerns included a perceived lack of staff skills and experience, and some people said that the care home was short-staffed.
People told us that they felt safe at the care home and received support when they needed it. People were happy with the quality of the food and told us they had enough activities to keep them stimulated. People said the care home was a nice environment with nice views and grounds.
Most relatives told us they were happy overall with the care their relative was receiving. Relatives felt their family members were safe and well care for. Relatives told us they felt welcome when they visited their family member and the care home was clean and tidy, with plenty of food options for their family members to choose from.