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Butterfly House Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 1 May 2020

About the service:

Butterfly House provides accommodation and personal care to adults whom are living with dementia. The service can support up to 36 people. At the time of the inspection 16 people were living at the service.

The service was located in a residential area of Weston-Super-Mare and was undergoing renovation and refurbishment to all rooms, communal areas and gardens.

People’s experience of using this service:

The service was in a transition period. Changes were being made to systems and processes, including the way people’s care and support was delivered. Staff were supported through induction, supervision and training. The provider was engaged in further development of the staff culture to support these changes.

Systems in place to monitor the and review the quality of the service were not fully effective. Further provider oversight was needed to ensure all areas were monitored and actions taken where required.

Care plans were being moved to a new system. Additional details were needed to ensure they were fully person centred and up to date. People received their medicines which were stored safely. We identified improvements needed in protocols for as required medicines and topical creams.

The service was clean and tidy. Extensive refurbishment work was in progress, which upgraded all facilities and improved accessibility. The environment and outdoor areas had been designed to support people’s needs who were living with dementia and promote people’s independence.

People spoke positively about the food provided. Feedback received demonstrated the service was proactive in regards to people’s health and social needs.

People received care and support from staff who were caring. People and relatives said there was enough staff to support them safely. Visitors were welcomed at the service. People said they enjoyed the activities facilitated.

People were supported to have maximum choice and control of their lives and staff supported in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update:

This service was registered with us on 28 February 2019 and this is the first inspection.

The last rating for this service was Good (published 21 November 2018). Since this rating was awarded the registered provider of the service has changed. We have used the previous rating to inform our planning process.

Why we inspected:

This was a planned inspection based on the date of registration.


We have identified a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at this inspection. Please see the action we have told the provider to take at the end of this report. We made two recommendations in relation to person centred care and current guidance in relation to as required and topical medicines.

Follow up:

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas



Updated 1 May 2020

The service was safe.

Details are in our Safe findings below.



Updated 1 May 2020

The service was effective

Details are in our Effective findings below.



Updated 1 May 2020

The service was caring

Details are in our Caring findings below.


Requires improvement

Updated 1 May 2020

The service was not always responsive

Details are in our Responsive findings below.


Requires improvement

Updated 1 May 2020

The service was not always well-led

Details are in our Well-Led findings below.