This inspection took place on 8 March 2017 and was unannounced. At our previous inspections in August and September 2016 we had serious concerns that the service were not safe, effective, caring, responsive or well led and people who used the service were at risk of harm. We had rated the service as 'Inadequate' and placed it into special measures.

This service had been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

During this inspection 8 March 2017 we saw improvements had been made to ensure people were provided with a safe, effective, caring, responsive and well led service. The provider had reviewed the internal management team and changes had been made. We judged sufficient improvements had been made. However, we will continue to closely monitor and review the service to ensure further improvements are made and people are provided with a safe service.

Butterhill House provides support and care for up to 28 people, some of whom may be living with dementia. At the time of this inspection 11 people used the service.

The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People received support from staff that met their individual needs and preferences, however, people were not always provided with opportunities to participate in activities that interested them.

People felt safe and staff knew how to protect people from avoidable harm and abuse. People's risks were assessed and managed to help keep them safe and we saw that care was delivered in line with agreed plans.

Medicines were administered and managed in a way that protected people from the risk of harm.

The principles of The Mental Capacity Act (MCA) 2005 were being followed as the provider was ensuring that people were consenting to the provision of their care and treatment. Where people lacked the mental capacity to consent they were supported by people who knew them to act in their best interests.

People were supported with their nutritional needs and monitoring was in place to ensure people ate and drank sufficient amounts.

Advice was sought from health and social care professionals when people were unwell. This advice was documented and followed by staff to maintain and support people’s physical and emotional wellbeing.

People were treated with dignity and respect and their right to privacy was upheld. The care people received was personalised and responsive to people's individual care and support needs.

There were enough suitably trained staff to keep people safe and meet their needs in a timely manner. Staff had been recruited using safe recruitment procedures which ensured they were of good character and fit to work with people who used the service.

The provider had systems in place to monitor and improve the quality and safety of the service. Improvements had been made to the systems in place to monitor accidents and action had been taken by the registered manager to reduce the risks of further occurrences.

People and staff told us that the registered manager and provider were approachable and staff felt supported to carry out their role.

We inspected Butterhill house in response to information of concern that people were continuing to receive care that was not safe. We previously inspected on 15 and 16 August 2016 where the service was rated as inadequate and placed into special measures. We had begun enforcement action against the provider and asked them to improve. We focused our inspection on the three areas of concern which were people's safety, the effectiveness and overall management of the service. We found that no improvements had been made since our last inspection and people were still receiving care that was not safe, effective or well led. We undertook this focused inspection on the 5 September 2016. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Butterhill House on our website at www.cqc.org.uk.

We found that the service remains Inadequate and it will remain in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Butterhill House provides accommodation and personal care to up to 28 people. At the time of this inspection 17 people were using the service.

There was no registered manager in post and the service was being managed by the provider and consultants who were in the process of registering as the new providers of the service. The new potential providers told us they had recruited a new manager who was due to start in October 2016. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not being safeguarded from abuse as incidents of potential abuse had not been reported or investigated to prevent the incident occurring again.

There were still insufficient staff to meet people's needs safely. People were at risk of malnutrion and infection due to a lack of care staff and domestic staff. The provider could not be sure that staff employed were of good character and fit to work with people.

People's medicines were still not managed safely. People did not always get their medicines at the prescribed times and were at risk of not having their medicines due to poor staff practise.

People's individual risk assessments were not followed by staff to en

This inspection took place on 15 and 16 August 2016 and was unannounced. At our last inspection in April 2016 we found that the service was not meeting the required standards. Regulatory breaches were identified and the service was judged to be requiring improvement. The breaches were in relation to the safe care and treatment of people, and safeguarding people from abuse and improper treatment. At this inspection we found no improvements had been made. There were continuing breaches in relation to the safe care and treatment of people, and safeguarding people from abuse and improper treatment. Four further breaches were identified regarding staffing, employing people, treating people with dignity and respect and governance arrangements.

The overall rating for this service is Inadequate which means it will be placed into special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Butterhill House provides support and care for up to 28 people, some of whom may be living with dementia. At the time of this inspection 21 people used the service.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Risks to people were not always minimised through the effective use of risk assessments. There were insufficient suitably trained staff to keep people safe and meet people's care needs in a timely manner.

Staff did not always have the knowledge and skills required to meet people’s individual care and support needs. The provider did not have robust recruitment and vetting procedures. Staff did not always have the induction, training and supervision they needed.

People did not receive care that was personalised and reflected their individual needs and preferences.

The principles of the Mental Capacity Act 2005 were not followed to ensure that people were consenting or being supported to consent to their care and support.

Care was not always personalised and did not meet people's individual needs. Advice from health professionals was not followed; therefore the action needed to relieve people from discomfort and distress was not taken.

People's medicines were not managed or administered safely.

Leisure and social activities were provide

This inspection took place on 26 April 2016 and was unannounced. At our last inspection in March 2015 regulatory breaches were identified and the service was judged to be requiring improvement. The breaches were in relation to the safe care and treatment of people, safeguarding people from abuse and improper treatment and treating people with dignity and respect. At this inspection we found some improvements had been made but more action was needed to ensure medication was administered and stored safely and people were not being deprived of their liberty unlawfully.

Butterhill House provides support and care for up to 28 people, some of whom may be living with dementia. At the time of this inspection 20 people used the service.

The service had a registered manager. However, the person currently named on our register was not the same person who was now managing the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Informal arrangements had been made to support people with their medicines if they needed them at night, however more formal arrangements were needed. Improvements were required to ensure the safe storage and administration of medicines.

The principles of the Mental Capacity Act 2005 were not consistently followed. People were at risk of unlawful deprivation. Referrals for a Deprivation of Liberty Safeguards assessment had not been made for some people who lacked capacity to consent to their care and treatment within the service.

Risks to people's health and wellbeing were identified and assessed but records were not always made with how to mitigate the risk. Action was not always taken to ensure people’s risk of harm was reduced.

Care staffing levels during the day were sufficient to meet the needs of people who used the service. Improvements were needed to make sure there were enough night staff available so that people were safe and had their support needs met in a timely way.

Limited leisure and social activities were provided for some people, but not all people got the support they needed to engage in any meaningful activity.

People generally told us they enjoyed the food and had enough to eat. Not all records for the purpose of monitoring people's fluid intake had been fully completed to ensure people's needs were fully met.

The provider had a system in place to assess, monitor and improve the quality of care. However improvements were needed to ensure a consistent approach to improving the service.

Staff were aware of the safeguarding procedures and knew where and to whom they could raise concerns.

The provider had a complaints procedure and some people knew how and who to complain to.

This inspection took place on the 4 March 2015 and was unannounced. At our previous inspection in June 2014 we found that the provider placed people at risk because of the unsafe storage and administration of medication. The provider did not offer enough stimulating and interesting things for people to do and people were not always involved in their own care planning.

At this inspection some improvements were noted in the environment, however further improvements were required. You can see what action we told the provider to take at the back of the full version of the report.

Butterhill House provides accommodation and care for 28 people. At the time of the inspection there were 24 people using the service.

There was a new manager in post. They had been in post for seven weeks and they were yet to register with us. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not always able to have their prescribed medicines because there were insufficient numbers of trained staff. People had not had their medication needs reviewed.

Systems to keep the home clean were not adequate. The communal areas required thorough cleaning and the facilities to handle waste need reviewing.

People were at risk of having their liberty restricted. The provider did not consistently recognise the requirement to work within the guidelines of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty safeguards (DoLS). The Mental Capacity Act (MCA) is designed to protect people who cannot make decisions for themselves or lack the mental capacity to do so.

People were not always treated with dignity and respect. Some observations had shown some staff to be disengaged and disrespectful. Care plans were not always followed to ensure that people remained independent and had the support they required. Consideration to people’s privacy had not been made in relation to the environment.

Some limited hobbies and interests were available within the home, however people were not being supported to access the community and they wished to.

People had their health and nutritional needs met. People were supported to attend health appointments and referrals to health professionals were made in a timely manner.

The new manager had begun to implement new quality monitoring systems to improve the service. People and their representatives felt that positive changes had been made.

We conducted an inspection at Butterhill House to check the progress the home had made in meeting the concerns we had raised at our previous inspections. The inspection was unannounced which meant the service did not know we were coming.

Below is a summary of our findings based on our observations of the service and people who used the service. We spoke with the staff who supported people and we looked at records. We considered our inspection findings to answer the questions we always ask –

Is the service safe?

The service placed people at risk because of the unsafe storage and administration of medication. We have asked the provider to tell us how they are going to improve their service in relation to medication practices.

The safety of people who used the service could be compromised because of the current practices with opening the fire doors and deactivating the alarms.

Staffing levels were assessed and monitored to ensure they were sufficient to meet people’s identified needs. Recruitment for additional staff was on-going.

Is the service responsive?

The home did not provide enough stimulating and interesting things for people to do. We have asked the provider to tell us how they are going to improve this aspect of people's care.

Swift and timely action was not taken when concerns with equipment for the storage of food was identified.

Is the service caring?

People say they were treated well and with kindness and care.

People and/or their representatives were not involved with planning, agreeing or reviewing their plan of care. We have asked the provider to tell us how they are going to include people with making decisions about their care, treatment and support.

Is the service effective?

People told us they had enough to eat and drink throughout the day, and night if required, and meals were flexible to meet their needs.

People’s day to day care and support needs were met.

Is the service well led?

The manager was aware of the improvements that were needed to the service. Plans for additional staff to be recruited, the replacement of equipment and the redecoration and refurbishment of the premises have been made.

At the time of this inspection the manager had been in post since January 2014. They were part way through the formal process of registration with us.

This was an unannounced inspection scheduled inspection. As part of this inspection we also looked at the progress the home had made in meeting the concerns we had raised at our previous inspections. During the inspection we spoke with people that lived at Butterhill House, relatives that were visiting, care staff, the manager and the nominated individual.

We considered our inspection findings to answer the questions we always ask;

• Is the service safe?

People were cared for in an environment that was now clean and hygienic. Improvements had been made in the standard of the premises although some areas still needed to be addressed. We have asked the provider to provide us with information about how it will continue to improve.

Staffing levels were sufficient to meet people's personal care needs. Some areas of training needed to be completed to make sure that people received care that was safe and appropriate to meet their needs. We have set a compliance action in relation to this and the provider must tell us how they plan to improve.

The CQC monitors the operation of the Deprivation of Liberty Safeguarding which applies to care home. Plans were in place for staff to receive the training to make sure that they understood when an application should be made and how to submit one.

• Is the service effective

People that lived at Butterhill House and relatives we spoke with were happy with the care provided. One person said: "They look after me well. I'm happy here".

People's needs were assessed and plans of care were in place. People had not agreed to their plan of care. People could therefore not be assured that the plans included information about how they wanted their care provided. People's nutritional needs were assessed and plans were in place to show the support they needed to have these needs met. There were some gaps in the food and fluid records. This meant that the people's nutritional intake was not monitored effectively.

• Is the service caring?

People told us they were supported by people that were caring and kind. One person said: "The staff are nice". A relative told us: "The staff talk nicely to people". We observed that care staff spoke with people in a friendly and respectful manner.

Care plans did not always fully record people's preferences about their social care needs. This meant that staff may not provide care in the way that people wanted.

• Is the service responsive?

The home did not provide enough stimulating and interesting things for people to do. We have asked the provider to tell us how they are going to improve this aspect of people's care.

The home had a complaints procedure. Information was available to people to tell them how to raise areas of concern. There had been no complaints since the appointment of the new manager.

People had the opportunity to complete a survey about the service they received. This meant that the provider was seeking people's views about their care to identify areas for improvement.

• Is the service well led?

The service had a new manager. The manager was not registered with us (CQC). We were assured that they were in the process of submitting a registration application.

The manager had begun to put in place a system to check the quality of the service it provided. This included reviews of people's care as well as audits on the environment, the home's infection control practices and risks to people. The manager had plans to develop this further to make sure that any shortfalls in care were identified and acted upon promptly.

The views of staff were now being sought. This meant that their views were being taken into account and areas of concern were able to be quickly highlighted and acted upon.

We undertook this inspection as a response to concerning information we had received. The inspection was unannounced. The manager and staff did not know we were visiting. We spent time talking with the manager and staff that worked at the home. We also spoke with some of the people that lived there. We looked at all the communal accommodation and 20 bedrooms.

People were not being protected against the risks of the spread of infections and the home was not being kept hygienic. We saw areas of the home that were not kept clean. This included bedrooms and communal rooms. The environmental health department had recently visited and had identified concerns over catering hygiene and safety.

The home was not being well maintained. Several areas including bedrooms needed attention to provide appropriate accommodation. Some areas of the home were not suitable as they did not promote people's privacy. Some bedrooms were interconnected and people could access other people's private accommodation.

There were inadequate numbers of suitably trained and experienced staff on duty to provide people with the support they needed. When there were insufficient care workers on duty ancillary staff were moved from their roles to provide care to people. This meant that there were not enough staff available to undertake domestic duties such as cleaning the home and undertaking the laundry.

This was a responsive inspection to follow up on issues we had raised when we completed our previous inspection. The manager did not know we were visiting. During this inspection we spoke with people that lived at the home, staff, the manager and two relatives.

People we spoke with said they were happy living at the home. Relatives said that they were satisfied with the care provided. One relative told us: "They treat my relative very well".

Following our last inspection the provider had sent us an action plan to show us how they were going to improve the service.

The arrangements for supporting people to have their meals had improved. Mealtimes were better organised and staff were available to provide people with the support they needed to eat and drink sufficiently. People's nutritional needs were assessed and the plan of care identified the support each person needed. People were provided with a choice of meals and could choose where to eat their food.

People were being supported to have their medication as prescribed. Staff had recently had training in managing medication and this included a check on their competency to administer medication safely.

The manager had put in place a number of checks to monitor the quality of care people received. Where shortfalls were identified these had been addressed.

This was a scheduled inspection and included areas where concerns were previously identified. When we last visited care staff did not have the knowledge and skills to work with people with dementia and people were not adequately supported to have their food and drink.

People and most relatives told us they were pleased with the care provided. They told us they liked the home and had seen improvements in their relative's health and wellbeing. People were having their physical and mental health needs assessed and plans of care were developed. The home monitored people's health and acted when people were ill.

Most people living at the home had dementia care needs. We saw examples of good interactions with people but saw some people were left alone for significant periods without having anything to stimulate and occupy them.

People were provided with choices of food and drink. Improvements had been made in the support people received to eat and drink but this support could be inconsistent.

Suitable arrangements were not in place to make sure that people had their medication as prescribed. Some records were signed before medication was given and there was too little time elapsed between morning and lunchtime medication.

A system to monitor the quality of care was being put in place but did not yet give sufficient information that appropriate care was provided and that any concerns identified and acted upon.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of an inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an Expert by Experience; people who have experience of using services and who can provide that perspective.

Some of the people living in this home were unable to tell us about the care and support they receive. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

We spoke with eight out of the 25 people living in the home and two people's relatives. Comments from these people told us that the home was improving since the consultant manager had started working in April 2012. The consultant manager told us that they had started working at the home due to concerns that had been raised. The consultant manager told us that they introduced improvements to the service.

Information about people's health and personal needs had been collected and recorded in new care plans. Details had been collected about people's past life and their interests. People's contacts with health professionals had been recorded. A relative told us that their relative looked better and had been taken out to buy new clothes, this had not happened for some time before. Another told us that an issue had been sorted out by the consultant manager. However, people had limited choices in how they spent their day and the food and drink they had. We found that people who were able to ask had more choices. For example if a person asked for a different main meal this would be given.

We received a number of comments from people who used the service and we received information that added clarity to some of the comments made. One person commented that "We are on a rota to have a shower;" we were advised by the provider that whilst people have a preferred routine there is no set rota and people can have a shower or bath when they choose. In respect of activities people commented "I used to play bingo" and “There is not enough for residents to do here, they need more stimulation”. We were informed by the provider that bingo had been stopped by request a short while prior to the inspection however because of the comment it would be suggested again as an activity to people who used the service along with other activities. In respect of food served and choice of meals one person commented, “This is a residential home and we just have to have what they give us.” Whilst we were informed that people could choose alternatives to meals that were served we noted that alternatives were not routinely offered or listed on menus.

We observed care staff did not always plan how they supported people with their meals and did not always talk to people when they were supporting them. We observed good interactions between people and the consultant manager.

This was an inspection to check that the home had made the improvements it told us it would make following our previous inspection. When we completed our last inspection we found that the home was not hygienic and did not have practices in place to control and prevent the spread of infections. We issued the provider with a warning notice. We also saw that the home did not have sufficient staff on duty to meet people's needs.

On this inspection we saw that improvements had been made although the home was not fully meeting the regulations.

People were living in a home that was much more hygienic. Policies and procedures were being put in place to make sure that home was kept clean and hygienic. Practices had recently been introduced to prevent and control the risk of the spread of infections.

The current staffing levels were adequate to meet people's personal care needs. There was little staff time provided to support people to take art in activities and to meet their social care needs. The manager was completing a full review of the home's staffing levels.