Bonhomie 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

We assessed 6 quality statements from this key question. We have combined the score for this area with scores based on the rating from the last inspection, which was good. We identified breaches of regulation relating to safeguarding and staffing. Immediate action was not always taken to keep people safe from abuse and neglect. Risks to people were not always fully assessed or action taken to mitigate these risks. We were not assured there were sufficient staff to effectively provide care that met people’s individual needs.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We were unable to collect sufficient evidence to score this evidence category.

Some staff told us they felt communication and information sharing was effective when people moved into the home. However, others did not and felt this was an area needing improvement. Leaders told us about work done to improve the pre-assessment process, but we found this had not always been effective.

A health and social care professional told us they had regular meetings with the service and felt they were kept up to date. Another said they felt staff had built a good relationship with a person they supported, and we saw examples of the home working with professionals to support a person with a smooth transition to another home. However, we also found there had been a delay in contacting relevant professionals following incidents with a person who had recently moved into the home.

The home supported a vast range of people with substantially different needs and across a wide range of ages. Staff completed pre-assessments to assess whether they felt they could meet people’s needs before admission. However, assessments did not consider compatibility, whether the home was the appropriate environment for the person they were assessing, or how people may interact with each other. This was not person-centred, and we found 1 instance where people had been exposed to ongoing harm when a person moved into the home. Although some historical information had not been shared with the provider, some sections of their pre-assessment were blank. We also found multiple completed sections indicated a need to obtain further information, but this had not been done. The person was later supported to move to another home in a more appropriate environment. However, we also saw an example of good practice where a person’s transition to the service had been well planned and supported.

Feedback from people was mixed. Some people told us they felt safe, however others did not and did not feel supported to raise concerns. Some people told us they did not see any point in raising concerns as they did not feel they would be dealt with. These views were shared by multiple people living at the home and were also reflected in our observations and other findings.

Staff we spoke with could tell us what they would do if they had safeguarding concerns. However, we found multiple incidents that were not identified or reported and did not always take people’s concerns seriously. Staff, including the registered manager, demonstrated they sometimes assumed allegations or concerns were false, and therefore did not report or investigate them appropriately. This meant we could not be assured people were protected from the risk of abuse. Following our inspection, the provider told us about actions taken to ensure concerns and allegations would be reported and investigated and maintain oversight of this. We also shared our concerns with the local authority.

People appeared comfortable around staff. However, we observed staff interactions and use of language was at times infantilising and disrespectful. For example, when a person knocked their wheelchair into another person’s foot they said, “[person] that was naughty”, and we saw another staff member repeatedly refer to someone by a nickname we were told they had not chosen.

Systems and processes were not effective to ensure allegations of abuse were always identified and reported. For example, we found a ‘concern meeting’ in a staff member’s file describing an incident where they were alleged to have shouted at a person living at the home. This was not recorded on the provider’s safeguarding log and was not referred to the local safeguarding authority or CQC. When concerns were reported, language used when describing allegations was dismissive and investigations were not robust. For example, a staff statement made during an investigation clearly demonstrated they had acted inappropriately. However, this information was not included in any investigation outcomes and no further action was taken. This exposed people to the risk of ongoing abuse.

Feedback from people about being supported to manage risk was mixed. Some people felt staff understood their needs and supported them safely when using a hoist, for example. However, some people we spoke with were not always confident staff understood their needs or how to best support them.

Some staff had a robust understanding of people’s needs and how to support them to manage risk. However, this was not always consistent, and some staff told us they did not have the time to ensure they were up to date on people’s risk assessments and care plans.

We saw some examples of staff supporting people appropriately to manage risk. For example, we observed people being supported to eat and drink in line with their assessed needs. However, we also saw examples of staff restricting people’s movement to manage risk. For example, asking people to sit down and placing a table in front of them.

Records lacked sufficient detail for staff supporting people with multiple and complex health needs, and we found information was not always consistent across records. For example, 2 records gave 2 conflicting pieces of guidance for staff to follow to support a person with risks associated with their diabetes. This meant we could not be assured staff would know which guidance to follow, exposing people to a risk of harm. Risks to others were not always assessed or mitigated, incident records lacked detail and were not used to identify triggers or learning to reduce distress and risk. For example, we found multiple entries in a person’s records that demonstrated clear potential triggers before incidents that had not been identified or followed up. Despite this, staff and management consistently referred to the person’s behaviour as “unpredictable”. Some risk assessments and care plans focused on impact to staff instead of the needs of the individual. However, we found some areas of good practice in positive risk taking. For example, a person had made the decision not to follow the advice of health professionals. Although this exposed the person to the risk of harm, risks were assessed to mitigate them while ensuring their decision was respected.

People’s feedback about the environment was mixed. Some people were happy with their environment, but others raised concerns and felt issues with the environment were not resolved in a timely manner. For example, ongoing issues with access to hot water and doors that were not wheelchair accessible. This was also reflected in our observations and other findings.

Staff told us they would report any faults or concerns about the environment. However, we found areas of concern with the environment. For example, the call bell system showed ‘pull cord fault’ on a minimum of 7 different in use call bells. A staff member told us they did not know if it had been reported, but it was just an error on the screen and the call bells still worked. We raised this with the registered manager, who confirmed it was a known issue, but they did still work. However, they were unable to tell us how they assured themselves of this, or how they would identify if they stopped working. Call bell logs showed a minimum of 3 of the call bells noted as faulty had not been used in the period reviewed, between 30 November 2024 and12 December 2024. This meant we could not be assured faults were or would be addressed in a timely way. This exposed people to a risk of harm if unable to summon help when needed.

Some areas of the service appeared clean and well maintained and work was ongoing to redecorate. However, there was a strong smell of urine throughout the home, which was not isolated to specific areas of the home or the time of day. We found the sluice was unlocked on 3 occasions in 1 day, and it was cluttered with items piled up around the sink, making the sink inaccessible. We found an open bathroom on the first floor filled with hoists, a wheelchair, drawers that contained a person’s care plan, and a ladder propped against the wall next to the door. When we raised this with a senior manager, they took action to address this.

Some checks were completed as required, such as services of hoists and electrical safety certificates. However, the concerns we identified demonstrated not all processes to monitor, report and rectify concerns about the environment in a timely way were effective.

People we spoke with told us they did not always feel there was enough staff, and we received mixed feedback about staff skills.

Most staff we spoke with told us they did not feel there was enough staff. One staff member told us they felt there was only enough staff to meet people’s basic needs, such as going to the toilet.

Staff appeared rushed and, although trying to, were not always able to respond to or proactively support people. This meant people who could not, or did not, actively ask for staff support had very little or poor interactions. For example, we saw a staff member ask a person who had been watching others do activities what song they would like played. However, the staff member was called to someone else and walked away before the person had an opportunity to respond. This happened 3 times in 1 hour and was the only interaction the person had in that time.

The provider was not able to demonstrate how they ensured staffing levels were sufficient to meet people’s needs. In addition, rotas showed the staffing levels did not always meet the number of hours on the provider’s support hours matrix. Recruitment processes were followed in line with legislation.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We could not collect sufficient evidence to score this evidence category.

Staff were aware of how to reduce specific risks associated with a medicine a person was prescribed. Staff knew how to store controlled drugs securely and maintain appropriate controlled drugs records. When we raised concerns about the age of written information available to support the use of medicines, staff knew where they could locate up to date information.

Only current fridge and room temperatures were recorded, which meant we could not be assured that medicines were consistently stored within their recommended temperature ranges. When medicines were prescribed to be taken ‘when required’, additional guidance to support administration lacked sufficient detail, personalisation and consistency. This meant we could not be assured medicines would be consistently administered to people when they were required. Covert administration is when medicines are administered in a disguised format, without the person’s knowledge. Although pharmacist advice on how this could be administered had been sought, this was not being followed. This meant we could not be assured the medicines remained active.