Bonhomie House

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was previously in breach of the legal regulation in relation to good governance. Improvements were not found at this assessment, and the provider remained in breach of this regulation. ​

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.

The provider did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

At the last assessment, we found concerns about culture and openness within the service. Feedback from staff and leaders was mixed. We identified a culture of blame and warning signs of a closed culture. These included staff perceiving decision-making processes as lacking transparency and feeling they had limited opportunities to influence or understand changes.

At this assessment, whilst the provider had taken steps to address these concerns, challenges remained.

Systems and processes had not ensured that all staff worked consistently across the service. Feedback from people and relatives relating to the experience of care was mixed, with some people reporting their experience was dependent on the staff memberproviding the support.

We also received mixed feedback from staff. Some felt there was a lack of clear direction and consistency in expectations, while others told us they understood the provider’s goals but felt these were not always embedded in day-to-day practice. This inconsistency contributed to variations in how care was delivered and how people experienced the service.

At the last assessment, we found concerns relating to leadership capability and culture, including disrespectful language used about people and weak governance processes. These issues contributed to poor practice and a lack of accountability across the service.

At this assessment, leadership instability had affected the service, resulting in inconsistent oversight and weakened risk management. Periods without stable leadership led to delays in identifying and addressing concerns, unclear accountability, and missed opportunities to improve care quality. Staff were not always aware of how senior leaders were supporting the service, which contributed to gaps in communication and oversight.

However, the provider had taken steps to strengthen leadership and improve oversight. A new manager had been appointed and was in the process of registering with the Care Quality Commission, and staff told us the management team was visible. Some staff were positive about the direction of the service and the changes being introduced, although this was not consistent across the workforce.

The provider demonstrated a commitment to developing and supporting staff, improving consistency, and fostering a person-centred, values-driven culture. Leaders were open about issues identified within the service and responsive to feedback during our assessment. People and their relatives spoke positively about the new manager and the improvements planned.

People did not always feel they could speak up and that their voice would be heard.

At the last assessment, we found staff were discouraged from following the provider’s whistleblowing policy, and feedback was often dismissed. This did not support an open culture or empower staff to raise concerns. At this assessment, the provider had taken steps to improve openness and encourage speaking up, although this was not yet fully embedded across the workforce.

The service had systems and processes in place to enable people and staff to speak up. A whistleblowing policy was in place, and we saw information signposting staff where to go for support and the processes to follow. The manager told us they operated an open-door policy and encouraged people, relatives and staff to speak up freely. However, not all staff felt confident to speak up or that action would be taken. Some staff told us it depended on the leader as to whether they would be comfortable speaking up.

Leaders demonstrated an understanding of their responsibilities under the duty of candour. The duty of candour is a legal responsibility for health and social care providers to be open, honest and transparent when something goes wrong with a person’s care or treatment.

Throughout the assessment, we found staff, leaders, and senior leaders to be open, honest, and transparent in their engagement with us. They responded to our enquiries with candour and demonstrated a willingness to reflect on feedback and acknowledge areas for improvement. This approach contributed to a culture where speaking up was encouraged and where concerns were increasingly seen as opportunities for learning and development.

The provider did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Some staff told us they felt diversity was not always fully celebrated, and there were concerns about fairness in how work was allocated. While leaders had taken steps to address these concerns and agreed protocols to promote fairness, this was not yet fully embedded across the service.

People were supported by a diverse staff team, and policies were in place to guide staff in their roles and promote equality. Staff shared examples of being supported through reasonable adjustments.

Staff confirmed they had opportunities to participate in team meetings, which allowed them to express concerns and contribute to discussions about service delivery.

The provider’s systems of accountability and governance had not always been followed and had failed to ensure people consistently received safe care.

At the last assessment, we found the provider did not have robust systems and processes to ensure compliance with regulations. Audits did not always identify shortfalls or learning, and when they did, action was not consistently taken. At this assessment, similar concerns remained. We continued to find gaps in risk management, care planning, and assurance processes, which meant the provider could not be confident that all areas of service delivery were effectively monitored.

Risk management processes did not reliably capture or document all relevant information. Accident and incident records lacked sufficient detail and analysis, and necessary actions to mitigate risks were not always recorded. Audits were completed but did not fully identify the concerns we found, including contradictory records and gaps in some staff employment records. This limited the provider’s ability to monitor service delivery effectively and act on performance data to drive improvement.

Leaders acknowledged the service had not improved as expected and told us they had recently taken action to address this. They recognised previous processes had not been effective or robust enough to identify sooner progress was slower than they believed.

However, leaders described changes made to improve accountability and ensure future improvements were delivered and sustained. These included introducing a new action plan with senior leader sign-off, upskilling staff, implementing a new management structure, and increasing on-site oversight. Leaders also worked closely with external professionals and senior leaders, supported by resources from across their organisation, to identify and drive improvement.

The service expressed a commitment to quality improvement. Leaders acknowledged improvements were still underway and demonstrated a willingness to drive change. While they were aware of some concerns, they had not recognised all of them, particularly in relation to restrictive practices and legal processes. Leaders were responsive to feedback and began taking action during the assessment.

The provider understood their duty to collaborate and work in partnership. They shared information with partners, and records were available to health and social care professionals when required. Where people needed support from outside services, such as attending appointments, the service ensured these were arranged.
Leaders and staff gave examples of partnership working with external agencies and professionals to improve care. This included working closely with social workers, mental health professionals, and community pharmacists to address people’s needs and drive improvements in the service. Feedback from professionals reflected this positive collaboration.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not consistently encourage creative ways of delivering equality of experience, outcome and quality of life for people, or actively contribute to safe, effective practice.

At this assessment, we identified shortfalls in areas such as care planning, risk management and assurance processes, which were similar to concerns found at our last assessment. This meant the provider’s approach to making improvements was not always consistent or effective in driving change.

Feedback from people, their relatives and staff indicated they had not consistently felt involved in shaping or evaluating improvement initiatives. Changes in management had disrupted continuity and impacted confidence in leadership.

However, leaders expressed a clear commitment to driving improvements. They described a clear ethos for learning and improvement and shared their plans to strengthen quality. At the time of the assessment, the provider was developing a detailed and comprehensive service improvement plan targeting several key areas of concern. This plan was informed by input from external professionals and their recommendations following recent visits to the service. Leaders also described actions to improve accountability and ensure future improvements were delivered and sustained.