Bonhomie Sarisbury Green

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

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has remained. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of the regulation in relation to safe care and treatment.

This service scored 59 (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 always thoroughly investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

Systems and processes to analyse incidents were not always effective, which meant opportunities for learning were sometimes missed. However, where shortfalls were identified we saw lessons were sometimes learnt and shared with the team, for example following medicines errors. Staff told us, and staff meeting minutes showed, incidents were discussed and feedback shared.

The provider worked with people and healthcare partners to establish and maintain continuity of care, including when people moved between different services.

Staff told us before people moved into the home, they received information to help them understand their needs and how to support them. A health and social care professional told us, “I found the service to be very proactive in assessing, planning the transition (including supporting my client viewing the placement prior), and settling the client into [their] new environment”.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff we spoke with could describe potential signs of abuse and gave examples of incidents they would report as safeguarding concerns. They told us they felt confident management would take concerns seriously. We saw evidence of safeguarding concerns being identified and reported to the local safeguarding authority. The provider made Deprivation of Liberty Safeguards (DoLS) applications as required when people were deprived of their liberty.

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

Information about people’s risk of choking and modified diets was not always clear or consistent. The chef had a good knowledge of the International Dysphagia Diet Standardisation Initiative (IDDSI), which provides a consistent framework for naming and describing food and fluid textures. However, other staff did not always demonstrate a robust understanding of how food needed to be prepared to meet IDDSI levels. This meant there was a risk people would not receive food prepared in line with their assessed needs.

There was inconsistent information and understanding about a person’s bed grab handle. Some care records and staff stated it was a bed rail to prevent them falling out of bed, and others stated it was used as a mobility aid to support getting in and out of bed. This meant we could not be assured it was being used safely and for its intended use, as described by the manufacturer. In addition, the provider had not completed a risk assessment to assess and reduce known risks with this type of equipment, such as entrapment.

Although staff we spoke with could describe how they supported people and knew people well, responses were sometimes inconsistent across different staff members and at times conflicted with information in risk assessments. This meant we could not be assured actions taken to reduce risk were consistent or accurate.

However, we found other risks were managed safely.

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.

There were ongoing renovations and maintenance work at the time of our inspection. On our first site visit, we found the shed in the garden with hazardous materials was open, accessible to people, and unattended. We raised this with management at the time but found at the end of the day it was closed but not locked. This was also identified as a concern in the provider’s own audits. Audits did not always identify areas in the environment that required maintenance, such as lifting flooring on the stairs, a cracked tile in a person’s bathroom and a bath seal that required replacing. Items identified in a fire risk assessment from the previous year were still outstanding in this year’s assessment. This was not identified in health and safety audits as each month’s audit stated the actions on the fire risk assessment had been completed. Fire safety equipment was serviced as required. There was clear guidance for staff in case of a fire and staff demonstrated they understood how to safely evacuate people.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

Safe recruitment processes were carried out in line with legal requirements.

Staff and people told us they felt there was enough staff to support people safely. There was a relaxed atmosphere in the home, and staff did not appear rushed.

Staff told us they received regular supervisions and felt supported. A person living at the home told us, “Staff are fantastic”.

The provider did not always assess or manage the risk of infection.

Some areas of the home would not be able to be effectively cleaned due to environmental damage and wear. For example, missing paint, a tile was cracked and porous materials being exposed. This was not identified in the service’s infection control risk assessment or audits.

The home smelt and was visibly clean, and PPE was readily available. We saw daily and deep cleaning schedules were completed. Cleaning schedules demonstrated the home was cleaned regularly and deep cleaning took place.

The provider did not always make sure that medicines were managed safely. When people were prescribed ‘when required’ (PRN) medicines, protocols were not always person-centred and lacked detail. For example, when to offer the medicine, what order to administer medicines when more than 1 was available, or when to escalate for review. We found 1 person was taking multiple PRN medicines daily, but staff had not escalated this to the GP for a review to identify if any changes were needed to the prescription to support the person’s health and wellbeing.

Medicines stock levels were not always recorded accurately.

Staff recorded opening and expiry dates on topical creams and liquid medicines. There were processes to ensure safe use and oversight of controlled drugs.