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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was previously in breach of the legal regulations in relation to safeguarding and staffing. Not enough improvements were found at this assessment, and the provider remained in breach of these regulations. ​

The provider was also in breach of the legal regulation relating to safe care and treatment.​

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Concerns about safety were not consistently listened to, and safety events were not reliably investigated or reported. Lessons were not learned to continually identify and embed good practice.

There was a failure to ensure openness, thorough investigation, and learning from safety events. For example, incident forms were incomplete and did not always give enough detail to help the staff and provider understand what happened. In some cases, such as incidents involving emotional distress, records did not clearly show what led up to the incident. Staff responses appeared reactive with no evidence proactive strategies had been considered or applied. This meant there were missed opportunities to prevent similar incidents from happening again. We observed this during the assessment, including occasions where people were not proactively supported. For example, when a preferred activity was unavailable, an alternative was not offered.

People mostly told us they felt able to speak to staff and leaders about their concerns and incidents that had occurred. However, they did not always feel kept informed or updated about the outcomes or actions taken. This reduced their confidence in the provider’s ability to respond openly and learn from events. Staff told us communication could be improved, as they were not always aware of actions completed.

There was no system in place for the regular analysis of incidents and accidents to identify trends, themes, and patterns. The lack of structured oversight limited the provider’s ability to recognise systemic risks, monitor the effectiveness of responses, and embed learning into practice.

These shortfalls reflected a systemic failure to foster a culture of safety, transparency and continuous improvement. The lack of detailed documentation, timely investigation, and embedded learning meant there was an increased risk of harm to people and staff. Leaders acknowledged improvements were needed in how incidents were documented and followed up.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

When people needed to go to hospital, the provider had clear systems in place to support them. This included using hospital passports, to give hospital staff important information about people and their health when they go to hospital.People were supported to arrange transport and were accompanied to routine health appointments and health checks. This helped maintain continuity and reduce risks during transitions.

People mostly confirmed they were supported to schedule and attend appointments as needed and supported to contact healthcare services and professionals. Relatives also confirmed people were supported to attend appointments where required. People told us they were involved in meetings with health and social care professionals, which promoted coordinated care and safe transitions. Staff shared examples of how they supported people to attend appointments, accompanied them during hospital stays, and described the steps they would take to ensure people’s needs were met during transitions.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. There were gaps in systems and practices that impacted the provider’s ability to protect people’s rights to live in safety, free from abuse, discrimination, avoidable harm, neglect, and unauthorised restrictions.

At our previous assessment, we found shortfalls in safeguarding practices and oversight. At this assessment, not enough improvement had been made, and repeated concerns were identified.

People gave mixed feedback about feeling safe, and 1 person told us they did not feel protected from psychological harm. The provider acted quickly to address this for the person, but this feedback highlighted a need for ongoing monitoring to ensure people feel emotionally and physically safe. A lack of emotional safety can indicate risks of psychological harm, neglect, or improper treatment. People told us communication was sometimes poor, which affected their confidence that action would be taken if they raised concerns.

Care plans lacked clear justification and safeguards for monitoring and checks. For example, surveillance and hourly checks continued without evidence of lawful authority or consideration of less restrictive options. This meant people were at risk of unauthorised restrictive practices and having their autonomy and rights undermined.

There were delays in reporting safeguarding incidents and gaps in oversight, meaning missed opportunities to prevent recurrence. Internal reviews confirmed staff had not always followed policies, resulting in repeated incidents before action was taken.

Although staff could describe safeguarding principles, the concerns we identified showed gaps in staff knowledge and practice when applying legal frameworks and responsibilities. The provider recognised this was an area for improvement and was working closely with the local authority to put effective actions in place, including more oversight from senior leaders and additional staff training. However, improvements had not been fully embedded at the time of the assessment.

The provider did not work well with people to understand and manage risks. Staff did not provide care that was safe, supportive, and enabled people to do the things that mattered to them.

At our previous assessment we identified inconsistencies in risk management and record-keeping. At this assessment, these issues remained and, in some cases, had deteriorated.

Risk assessments were not always person-centred or updated when people’s needs changed, and some lacked clear strategies for managing foreseeable risks. For example, care plans were not always updated after incidents, and actions to reduce risks were not recorded. This meant staff did not always have the guidance they needed to provide safe, consistent care, increasing the risk of harm.

Care planning records did not consistently reflect current support needs, and some contained outdated or contradictory information. For example, care plans did not always include strategies for managing emotional distress or fire risks from emollients (skin creams that can become flammable if they build up on clothing or bedding). This increased the risk of unsafe or inconsistent care and limited people’s ability to be active partners in managing risks.

People gave mixed feedback about their involvement in care planning and risk assessments. Some told us they felt included and listened to, while others said they were not involved or did not understand how risks were managed. Staff also told us they felt risks were not always managed effectively, particularly when supporting people experiencing emotional distress. They told us strategies to prevent incidents were not consistently in place, reviewed, or shared across the team.

The provider had identified this as an area for improvement and had a detailed action plan to address these shortfalls. They were working closely with external professionals to strengthen risk management and provide additional staff training.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

At our last assessment we identified concerns about the provider’s ability to detect and control environmental risks, and ensure facilities consistently supported safe care. At this assessment we found similar concerns.

Feedback from people, relatives, and staff was mixed about the environment and how quickly maintenance issues were resolved. For example, some of the feedback noted it could take repeated requests for maintenance concerns to be addressed. People and staff were not always aware when maintenance concerns had been resolved, and there was some confusion about whether hot water was consistently available. However, people confirmed they had the equipment they needed and it was available for them to use when required.

We found gaps in oversight and continuity of premises-related safety measures. For example, fire safety actions from a previous inspection by the fire service had not been completed.

The provider acknowledged challenges with maintenance and oversight, which had affected how quickly issues were resolved. They explained this was partly due to vacancies in the maintenance team and changes in service management. Before our assessment, the provider had identified shortfalls and taken steps to address them. This included recruiting to fill vacancies and implementing systems to improve monitoring and accountability. At the time of our visit, a full maintenance team was in place, and records showed checks such as equipment servicing and water safety were being completed and monitored. The provider was also taking steps to address the outstanding fire safety actions and strengthen oversight processes.

The provider did not make sure there were enough qualified, skilled, and experienced staff. They did not make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

At our last assessment, we identified concerns about staffing levels and staff skills, including how well staff were able to engage with and support people. At this assessment, we found similar concerns remained, particularly around staff training, supervision, and deployment.

Records showed staff were not always given appropriate training, support and checks to make sure they were confident and able to provide safe, personalised care. This meant there was a risk staff may not always have the skills they need to support people well.

People, relatives, and staff told us they were concerned that some staff, including agency staff, were not always fully trained to meet people’s individual support needs. Some staff training records and some agency staff profiles did not show clear training dates or confirm staff had completed relevant training in key areas. Such as learning disabilities, autism and mental health. This meant there was an increased risk that staff were unable to provide safe, effective, and person-centred care, especially for people with more complex needs.

Most people and relatives told us there were usually enough staff on duty day-to-day. However, they also told us the mix of skills and experience was not always effective, which sometimes affected the quality and consistency of care. We observed mixed levels of staff engagement with people and saw examples where staff were less confident or did not engage well with people.

The provider had identified these shortfalls through their own governance systems and shared the actions they had taken, and planned, to address concerns. These included changing how staff were deployed, providing training (including targeted re-training), and making sure staff had regular supervision and support. Additional resources, such as more laptops, had been provided to enable quicker access to online training.

The provider did not always assess or manage the risk of infection effectively or consistently detect and control the risk of it spreading.

Although we observed regular cleaning during our assessment, and staff confirmed this, some areas of the home were not visually clean. This included marked soft furnishings, damaged walls and floors, and metal strips that made effective cleaning difficult. We also noted visible marks on walls and a strong malodour in parts of the home at times. Persistent malodours can affect people’s comfort and dignity and may indicate underlying issues that require further action. Such as damaged flooring or furniture that cannot be properly sanitised, or issues with continence care. Personal protective equipment (PPE) stations were also not consistently stocked throughout the home.

Feedback from people and relatives was mixed. Some told us parts of the home could be cleaner, while others felt standards had improved. One relative told us, “The place is cleaner now… it used to be filthy.”

Staff and leaders were responsive to feedback and took prompt action when concerns were raised, such as restocking PPE stations and cleaning highlighted areas. However, these shortfalls showed that cleaning routines and infection control measures were not always robust.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

At our last assessment, we identified concerns about incomplete records and insufficient guidance for ‘as required’ medicines. At this assessment, we found similar concerns.

We found gaps in medicines documentation, including missing entries in temperature logs, delivery checks, and medicines administration records (MAR). Medicines returned to the pharmacy were not recorded, which compromised traceability and accountability. Medicines care plans lacked clear guidance for staff, particularly for ‘as required’ and variable dose medicines (where the amount can change depending on the person’s needs at the time), and reasons for administration or outcomes were not consistently recorded. These shortfalls increased the risk of people not receiving their medicines as prescribed and reduced opportunities for timely review.

People told us they were generally supported with their medicines and involved in reviews. One person told us, “They go over your meds, check you know what medicines you have and if you still need it.” Staff told us they had completed medicines training. A relative told us, “No problems regarding medications.” Staff confirmed, and we observed, that medicines were stored securely and in line with the provider’s policies and procedures.

Following the assessment, the provider was being supported by external professionals to review and strengthen their medicines systems and processes.