Butterley House

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. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The provider had processes in place for recording incidents and accidents and used an electronic recording system for recording care notes. However, no analysis had taken place of this data, meaning that learning could not be taken from it. This meant people could be exposed to the same risks on multiple occasions, if the root cause of accidents and incidents had not been identified.

For example, one recorded incident related to a member of staff being involved in an upsetting incident with a service user. In the incident report it stated this was, ‘Not the first time’ an incident of this nature had happened. There were no recorded details of what actions were taken as a result of the incident, and no analysis of trends within the incidents which had been recorded. This meant the opportunity to learn from the incident and alter the care plan approach had been missed, creating a risk that incidents would continue to occur which would place people and staff at risk.

However, staff told us they felt comfortable in raising any concerns they may have with leaders and considered leaders would support them and provide guidance.

The provider did not always work well with people and health system partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Staff did not record fluid charts accurately. This was of particular concern due to the risk of dehydration posed to service users by the extreme heat during the time of our assessment. Staff and leaders assured us people were receiving adequate fluids, however, several people’s care records recorded they had been offered and had consumed well below the recommended daily allowance of fluids. This meant people were at risk of dehydration, as staff would be unable to look at records and identify how much fluid each person had consumed, and therefore how much more they required.

Staff used an electronic care planning system to access care plans and record information. These devices were linked to mobile phones which each staff member used to access the system. There were QR codes in people’s rooms which allowed staff to scan the code and instantly access the relevant person’s care plan and notes. Whilst these systems were in place, they were not always used effectively which placed people at risk. For example, a system which warned staff about people not consuming sufficient food or drink was not set up on a person’s care plan. This led to the person being placed at risk of harm because staff and leaders had not noticed the person had not had sufficient food and fluid intake.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans reflected people’s current needs and people had been consulted and involved in the care planning process, where they were able to be involved. For example, people who lived upstairs told us they were happy to use the stairs and could receive support from staff if they needed it. Care plans for people living upstairs reflected their current level of mobility. Another person’s care plan stated that they were ‘independent with eating, drinking and going to the toilet, but would prefer staff supervision’. This showed the provider had recorded the person’s preferences, as well as their needs.

One family member told us, “Yes, my relative is safe at the home. They are not very mobile and the staff routinely check in on them to make sure they are okay.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans reflected people’s current needs and people had been consulted and involved in the care planning process, where they were able to be involved. For example, people who lived upstairs told us they were happy to use the stairs and could receive support from staff if they needed it. Care plans for people living upstairs reflected their current level of mobility. Another person’s care plan stated that they were ‘independent with eating, drinking and going to the toilet, but would prefer staff supervision’. This showed the provider had recorded the person’s preferences, as well as their needs.

One family member told us, “Yes, my relative is safe at the home. They are not very mobile and the staff routinely check in on them to make sure they are okay.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The stairs leading up to service users’ rooms were steep and narrow, partly due to a stairlift fitted on one side of the staircase. Leaders told us people who live upstairs were assessed for their mobility to ensure they could safely access the stairs, and an alarm prevented people from accessing the stairs without the knowledge of the staff. We raised concerns with leaders that there was no gate on the stairs, presenting a risk of people falling. The interim manager took these concerns on board and mitigated the risk, with gates fitted at the top and bottom of the stairs.

Environmental checks were completed on a regular basis and actions were taken when issues were found.

A lot of equipment such as hoists, shower chairs and commodes were new and had been replaced since our last visit in November 2025, showing the provider had responded to previous concerns raised by us and the local authority in this area.

The care home was relatively cool given there had been a heatwave for some weeks prior to and on the day of our visit. There was a thermometer in each room which allowed staff to monitor temperatures and ensure people were kept safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider ensured there were sufficient staff to cover each shift. Some permanent staff had recently left the provider and agency staff were being used to provide cover, however there was a majority of permanent staff working on each shift. The interim manager advised us they had recently changed the care agency to one which they had worked with previously and trusted and created a more rigorous induction process.

Staff were observed to be kind and compassionate towards people, and the people we spoke with agreed with this. Staff were knowledgeable about people and their needs, knowing how to support them effectively.

There were recruitment processes in place to ensure new staff were suitably qualified and safe to work in their roles. The interview process showed the provider assessed staff’s suitability for the roles they were applying for.

Whilst the staff we spoke with told us they were happy and felt supported working for the provider, they stated there had been changes and upheaval with leaders, which had resulted in some staff leaving. Staff said they felt this had now settled down.

People were positive about the support they received from the staff. One person told us, “If I wasn’t happy I would tell the staff. I’m not sure who the manager is. The staff are nice though, I’d tell them and get them to sort it for me”. Another person said, “Staff are kind, they make me feel at home”

However, relatives gave mixed feedback about staffing levels, with around half of relatives we asked saying they did not believe there were sufficient staff. One person told us, “No, there’s not enough staff. There should be more in the communal rooms where people are ata high riskof falling. I think my relativewouldn’thave fallen if they had more staff. Half the staff have been there since my relative went in and the other half are more recent.” Another relative said, “I’mnot sure.I’venoticed therehasn’tbeen a member of staff in the conservatory with the residents. The summer fayre was cancelledbecausetheydidn’thave enough staff. My relative says they have towait to go the toilet.” On the day of our inspection we observed there were sufficient staff to keep people safe, and staff rotas for the past month showed sufficient staff had been placed on the rota to meet people’s needs.

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 care home was clean and tidy, and cleaning staff were on duty. Housekeeping staff were knowledgeable and explained the systems which were in place for laundry.

The provider had an infection control policy in place which was informed by national legislation and good practice guidance. This meant cleaning staff were following the most current practices.

Staff were observed using appropriate Personal Protective Equipment (PPE), with well-stocked PPE stations available at intervals around the care home. The provider observed Control of Substances Hazardous to Health (COSHH) regulations, ensuring hazardous substances were stored in locked areas of the care home where they could only be accessed by qualified staff.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The medication room and drugs trolley were tidy and organised. Protocols were in place for the administration of medication and guidance was clear and easy to follow. Medicines administered were recorded on paper medication administration records (MAR), and these charts were orderly and corresponded with medication stock counts.

Leaders and staff who administered medication were knowledgeable and able to explain any questions related to medication. The medication lead was knowledgeable regarding different people’s medications, they were able to explain each medicine the person was taking and why they were taking it. They were also able to provide examples of when they had liaised with clinicians such as the GP to enquire about changes to people’s medicines, and pharmacist in order to or clarify queries about dosage or administration.

There were regular reviews of people’s prescribed medicines which were recorded in their care notes, ensuring medicines were optimised for people’s health and wellbeing.

Staff received training and had to shadow experienced staff and administer medication under supervision before being signed off to administer medicines on their own.