Butterflies Care & Support Ltd

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

At this inspection, we found 3 breaches of regulation regarding safe management of risks and medicines, quality assurance systems and staff support and development.

Systems to ensure safe, effective and high-quality care were not in place or not used consistently. There was no effective oversight of the service by the provider and registered managers. The registered managers did not have effective processes to monitor risk or staff performance. Audits were not in place and learning was not embedded. This meant risks were not always identified or reduced.

Care planning and risk assessment were not detailed enough to support staff awareness of people’s health conditions. Important information about risks were not always recorded or supported with clear guidance. Medicines were not always managed safely and concerns were not escalated to health professionals.

Safeguarding systems were not consistently applied and staff knowledge varied. Training, supervision and competency checks were not effective, which meant staff were not always fully supported to deliver safe care.

Staff did not always work well with other services. Important information about people’s care was not always shared clearly or in a timely way. People were not always given a clear way to raise concerns, and the provider could not show how they learned from feedback or made changes to improve the service. The provider was unable to demonstrate how outcomes for people were monitored, reviewed or improved over time. This meant there was no clear evidence that people’s care was regularly checked to make sure it was effective or that their quality of life was getting better.

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Despite these concerns, people and relatives gave positive feedback about staff. There were examples of caring and responsive support, and some effort to work with other professionals and improve care.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.

We have asked the provider for an action plan in response to the concerns found at this assessment.