- Care home
Bonhomie House
Assessment report published 10 February 2026
Contents
Ratings
Our view of the service
Date of assessment 24 September to 10 November 2025.
Bonhomie House is a nursing home providing nursing and personal care for up to 78 people. At the time of our assessment 51 people were using the service.
This unannounced assessment was completed in response to concerns received about the service relating to the environment, staffing and safe care and treatment. We also checked to see if improvements had been made following the Warning Notice issued in relation to good governance at the last assessment. We undertook a comprehensive assessment and reviewed all 33 quality statements related to the 5 key questions, Is the service safe, effective, caring, responsive and well-led?
At the last assessment we found 5 breaches of the legal regulations in relation to dignity and respect, need for consent, safeguarding people from abuse and improper treatment, good governance and staffing. At this assessment we found 4 continued breaches of the legal regulations in relation to dignity and respect, safeguarding, good governance and staffing, as well as a breach in relation to safe care and treatment.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance Care Quality Commission (CQC) follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it. We found the provider did not always meet the requirements of this guidance. People were not consistently treated with dignity and respect, and care plans lacked sufficient detail to guide safe, effective, and person-centred care. The provider did not always have arrangements in place to protect people from improper treatment, and consent was not always obtained in line with legislation and best practice.
The provider had an inconsistent approach to risk management. Risks to people’s health and safety were not always assessed, and appropriate actions were not consistently taken to reduce these risks. Systems and processes for managing medicines safely were not always effective.
The provider did not always ensure there were enough qualified, skilled, and experienced staff to deliver effective, person-centred care. This meant people’s needs were not consistently met. Leadership instability had affected oversight and weakened risk management. Although governance arrangements existed, they were not operated effectively to monitor and improve the quality of care. However, we found no evidence that people had been harmed.
The provider was previously in breach of the legal regulations in relation the need for consent. Enough improvements were found at this assessment, and the provider was no longer in breach of this regulation.
Progress since the last inspection had been slowed by leadership instability, which had impacted oversight and delayed improvements. Recent actions to strengthen leadership were beginning to drive more consistent progress. Staff and leaders engaged openly and transparently throughout the assessment, demonstrating a commitment to learning and improvement. The provider had a detailed service improvement plan and was responsive to feedback throughout the assessment, taking action and identifying steps to address the concerns and strengthen their improvement plan. They worked collaboratively with external professionals and organisations to support and drive improvements. Leaders acknowledged that improvements were still underway but demonstrated a clear commitment to making changes that would be sustained and fully embedded.
We have asked the provider for an action plan in response to the concerns found at this assessment, and we will meet with them once it is received to closely monitor progress and ensure all improvements started during the inspection are fully completed.
People's experience of this service
People’s experiences of care were mixed. Most people told us they felt able to speak to staff and leaders about concerns and described the manager as accessible and approachable. One person told us, “[Manager] tries to sort out problems … nothing is perfect of course…but she tries.” A relative told us, “The new manager responds to emails and phone calls.”
However, people and their relatives did not always feel informed about the outcomes of concerns raised or the actions taken, which affected confidence in the provider’s ability to respond transparently and learn from events. One relative told us, “We’d like more feedback from the home.”
People did not consistently feel safe or supported to manage risks. Care plans and risk assessments were not always person-centred or updated, and records often lacked meaningful detail about people’s lived experiences. Feedback about involvement in care planning was mixed; some people felt included, while others did not understand how risks were managed. One person told us, “I am not involved in any care plans … they will update the care plans without you.” A relative told us, “They discuss her care plan, anything to add to lead to more independence.”
Staffing levels were generally sufficient, but people and relatives raised concerns about skill mix, training, and deployment. We observed mixed interactions, some lacked empathy and explanation; for example, staff did not always communicate with or seek consent from people when providing support, such as explaining before putting on clothes protectors or before moving someone in their wheelchair.
One person told us, “They [staff] will come in … leave the wardrobe doors open, drawers open … just think some of them need to think more what they would do if it was their mum or sister’s or their house.” Although there were also some positive examples where staff respected people’s independence, dignity, and privacy. One relative told us, “Yes they are kind … they’ll stop and respond.”
People confirmed they had access to equipment and professional advice and were supported to attend appointments. However, some relatives expressed concern that health needs were not always monitored effectively, which could delay early intervention. Comments included, “Some carers don’t know how to assess or treat his skin” and “They don’t know what mental health is.”
Opportunities for meaningful engagement and community-based activities were limited. While some activities and 1:1 sessions were well received, people told us there were delays and missed opportunities, including limited variety and frequency of activities and delays caused when staff needed to support people to attend, which shortened the planned time for scheduled activity sessions. Bedrooms were personalised, and some people spoke positively about goals they were working on with staff, but this was not consistently reflected in care documentation. Comments included, “She’s got a lovely room” and “She can generally cook for herself. Her confidence is growing every day.”
Overall, while there were some examples of good practice, shortfalls in communication, involvement, staff competence, and consistency of care meant people were not always receiving safe, person-centred support that upheld their rights, dignity, and wellbeing. We found examples where people’s human rights were not consistently respected, such as restrictive practices without clear legal basis and care that did not always promote autonomy or privacy. People with a learning disability and autistic people did not always experience care that supported their quality of life in line with Right Support, Right Care, Right Culture. One relative reflected, “There is still work to do but it is going in the right direction. I feel very positive.”