Butterley House

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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 governance at the service.

This service scored 50 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Some relatives we spoke with expressed their concerns around the uncertainty with leadership. One relative told us, “There’s a lack of information about the rapid management changes. I’m not sure what’s happening. Apparently, they’ve left letters about the changes for families to pick up when they visit”. Another relative said, “There was a change of manager earlier in the year. We received a letter saying please come in and meet the manager and then last week we were told there was an interim manager. Nobody has said why the previous manager left”.

Staff were positive about the culture of teamwork and said leaders were approachable.

The provider had policies in place which displayed a commitment to direction and culture. Policies and procedures around staffing were inclusive, and reasonable adjustments were made for staff who required this. A business continuity plan was in place.

The interim manager had made positive changes and was in the process of creating an action plan for improvement. Staff we spoke with were committed and told us they trusted the leadership of the interim manager. However, there were many changes identified on the action plan which were not yet embedded. As the leadership and governance of the provider has been unstable, we could not be fully assured the provider held a shared direction and culture.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The interim manager was knowledgeable and had implemented some positive changes to the service and had created an action plan for improvement. However, these changes were not yet sustained or embedded in the service. The previous registered manager had only been in post for a short period of time before leaving their role, and there was a clear lack of continuity and leadership which had also been identified during our previous inspection. The Nominated Individual informed us they were actively in the process of recruiting for a new registered manager, however at the time of the assessment there was no registered manager in place.

One relative who we asked about leadership stated, “This question is difficult to answer because there have been so many management changes and Idon’tknow what my relative’s care is like, I have no idea.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a ‘Freedom to Speak Up’ policy which identified a step-by-step approach for staff to raise concerns and the policy advised of external methods of whistleblowing including contacting CQC, and provided signposting to advice for any staff member who wished to speak up about an issue.

All staff understood the concept of whistleblowing and freedom to speak up, and said they felt that they could approach leaders if they had a concern.

The provider valued diversity in their workforce. They worked towards an inclusive and fairculture by improving equality and equity for people who worked for them.

Staff told us they enjoyed working for the provider and felt they could approach leaders with concerns. Staff told us they felt safe at work. Some staff told us they felt they were supported to develop their career, and there were examples of staff progression from carer roles into senior carer and leadership roles within the home.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We were notified us of a person who had to be hospitalised following a period of not eating and drinking. Alert systems available on the provider’s electronic care planning system had not been set up which could have warned staff about these concerns earlier, and reduced the risk of harm. This showed a lack of appropriate recording, combined with a lack of effective systems and suitable governance.

The provider were unable to locate the previous medication audit when we requested this information. Leaders advised us they could confirm that a medication audit had been completed in March 2026, but this could not be located. This meant there was no evidence of medication having been audited for 4 months increasing the risk of medication errors not being recognised.

Staff told us the interim manager had brought stability. However, the concerns we found in respect of governance and leadership were consistent with concerns we had during our last inspection in November 2025. Whilst the interim manager was in the process of creating new systems and making positive changes, it was clear there had been no continuity in governance for some time. The lack of consistent processes and systems placed people at risk of harm.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider did not have records of any recent resident meetings. This showed resident meetings were not being documented and used as opportunities to learn and improve the service quality based on the feedback received. We spoke with staff and leaders who advised resident’s meetings had taken place; however, the provider could not provide us with recent evidence of these.

Relatives told us they did not think the provider communicated with them effectively. One told us, “No, we’re not properly informed and I’ve had to chase them up about things”. Another said, “It would be good if they could produce a monthly newsletter for families telling us what’s what”.

However, the provider understood their duty to collaborate and work in partnership, they shared information and learning with partners and collaborated for improvement.

External professionals including district nurses GPs and social workers visited the service regularly. Meetings were held , with any changes to people’s care being recorded in their care plan and communicated to staff through shift handovers and meetings.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

Systems were not effective in promoting learning from incidents and reducing the risk of recurrence. For example, accidents, incidents and antecedent, behaviour, consequence (ABC) charts were recorded on the provider’s electronic care records system, with details such as the date, time and nature of events documented. However, there was no evidence this information was routinely analysed to identify patterns, trends or recurring themes. The interim manager confirmed they were unable to locate any records of analysis relating to accidents, incidents or falls and did not believe this had been undertaken for a considerable period. As a result, the service was unable to demonstrate that information collected was being used to drive learning, inform improvements in practice, or implement preventative measures. The absence of effective oversight meant opportunities to identify emerging risks and take proactive action were missed, increasing the likelihood of similar incidents reoccurring and placing people at continued risk of harm.

Similarly, falls data was recorded on the provider’s electronic care system and included information such as the number of falls occurring each month, the location of the fall, whether it was witnessed, any resulting injuries and the date the incident was reported. However, there was no evidence that this information was being analysed to identify patterns, trends or recurring risk factors.

Complaints and compliments were not logged centrally and there was no evidence of a system being in place to record complaints. Compliments cards were on display in the entrance area, but not logged anywhere, and one complaint from several years ago being on record. This again showed the provider was not recording compliments and complaints and using these as learning opportunities to improve the quality and safety of care delivery.

The interim manager advised us they were unable to locate any analysis of falls data and did not believe this had been undertaken for some time. As a result, the service could not demonstrate learning was being taken from falls or information was being used to inform preventative actions and risk reduction strategies. The lack of effective analysis meant opportunities to identify emerging concerns and implement measures to mitigate risks were missed, increasing the likelihood of further falls and associated injuries for people using the service.