Bonhomie House

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• 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

We assessed 5 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 regulations relating to dignity and respect, consent to care and treatment, safeguarding, good governance and staffing. The provider did not have effective governance systems in place to ensure people received safe, effective and good quality care.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from staff and leaders was mixed. Some staff shared positive feedback and felt there was a positive culture in the home and staff team, but others shared concerns. Some staff who shared concerns expressed they would not feel safe to raise these with the registered manager or provider. There was a culture of blame throughout the home, and we found multiple occasions when the registered manager’s focus in responding to concerns was to identify who had raised them and why. This did not encourage an open culture and meant opportunities for support and learning were missed. During our inspection, the registered manager resigned from their role.

We identified multiple warning signs indicating a closed culture had developed. The provider did not have processes to prevent this and had not identified it. For example, staff meeting minutes dated 09 October 2024 stated, ‘[registered manager] did not know that [person] had been assessed and had to lie to [nominated individual] to pretend she knew”. People with a learning disability were repeatedly referred to as “the LD residents”. In addition, we found a minimum of 17 incidents between 03 September 2024 and 22 October 2024 were not referred to safeguarding or notified to CQC as required. This exposed service users to the risks of harm associated with closed cultures.

Staff at all levels did not always speak or write about people with kindness or respect. For example, 1 staff member told us part of safeguarding was ensuring people were “fed and watered” and we saw incident records that referred to people as a “nuisance”, “narcissistic” and “difficult to manage”. However, we also observed some positive interactions and staff speaking of people fondly. We received mixed feedback from staff about management of the service.

The provider did not have robust processes in place to identify concerning practice and take action to improve. Although we found some areas of good practice, a lack of effective governance meant this was not consistent or sufficient to mitigate the potential impact of poor practice on people.

We received mixed feedback from staff about whether they felt able to speak up. Some staff felt able to raise concerns but were not always confident they would be listened to. We saw staff survey results that demonstrated staff had provided feedback and raised concerns, but these had been dismissed. For example, in 1 survey, 7 staff reported they felt they were not listened to. The response stated comments did not give sufficient context and the only action recorded was to monitor allocations and shift patterns. However, a comment in response to 2 staff answering they did not feel they had sufficient training stated, ‘there is no need for staff to feel they do not have enough training’. This was dismissive of staff feedback, and did not identify any potential links to the answer to the previous question.

The provider had a whistle blowing policy and process available for staff to raise concerns. However, we saw meeting minutes that showed staff were discouraged from following the provider’s policy. This meant we could not be assured staff were supported, empowered or encouraged to raise their concerns. Staff and resident survey results and meeting minutes showed people and staff were raising many of the same concerns, but this information was not used to inform action planning or make improvements.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Feedback and management of the service was mixed. Although there was a clear management structure, there was not always a clear understanding of roles, responsibilities and accountabilities. For example, recording and reporting incidents.

The provider did not have robust systems and processes in place to ensure they were compliant with the regulations. Audits did not always identify shortfalls or learning. When they did, action was not always taken to address these. For example, almost all items on an action plan dated May 2024 were overdue. A bimonthly audit stated the months incidents had been reviewed and, ‘all residents with entries are usual clients and nothing was different or concerning’. This did not demonstrate any learning was taken from incidents to reduce the risk of recurrence, and we found a minimum of 2 incidents in the period covered that had not been reported as required. During and after our inspection, the provider told us of actions they intended to take to improve.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.