Bonhomie Sarisbury Green

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• 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

During our assessment of this key question, we found concerns around the management of people's medicines and the ways in which people were involved to manage risks. We also found accidents and incidents were not effectively investigated, reported thoroughly or lessons learnt to reduce risk of recurrence and mitigate risks. This has resulted in a continuing breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. The provider was not always promoting safety through the cleanliness, maintenance and upkeep of the premises. People felt protected from abuse, but safeguarding concerns had not been notified to CQC. Partner agencies lacked confidence in how the processes and systems in place were operated to keep people safe from abuse. There were suitable staffing levels.

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 registered manager maintained a log for safeguarding issues, complaints and concerns. This gave some assurances concerns raised by people and staff had been listened to and acted upon. However, the log did not include a complete record of all of the safeguarding concerns that had occurred within the service and therefore this process was not an effective tool to ensure the registered manager had full oversight of all safeguarding events and did not promote learning opportunities to keep people safe. A culture of safety and learning needed to be further embedded. Accidents and incidents were being monitored and reviewed. However, this was not always effective. There was a lack of detail in the recording of incidents which did not enable effective review to identify lessons learnt and measures needed to reduce the risk of reoccurrence. For example, where there had been incidents of emotional distress for people, it was not detailed how the person had communicated their distress, or what specific techniques staff had used in response. This meant the person’s care plans and risk assessments were not reviewed and updated to reflect any changes or positive approaches identified. We also saw incident forms relating to events where people had sustained an injury, but the incident form did not describe how the injury occurred. Similar issues were identified by a healthcare professional (HCP) who shared concerns about a lack of robust review of incident forms by the management team. They were concerned that the current approaches did not always identify future risk mitigation, learning opportunities or the need to update care plans and risk assessments. They added that they were aware the registered manager had told them they had shared practice related concerns with staff members, but that there was a lack of evidence as to what measures had been implemented to prevent a reoccurrence.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The registered manager expressed a commitment to keep people safe from harm and could describe their role and responsibilities in relation to safeguarding. However, safeguarding incidents had not always been monitored robustly or notified to the Care Quality Commission as required. Therefore, we were not assured the registered manager always applied their knowledge in practice. Staff told us they had training on how to recognise and report abuse. They were confident any concerns brought to the attention of the registered manager would be acted upon. Staff comments included “[Safeguarding] is about protecting clients from abuse and neglect and if they say something we have to listen to them and try to protect from rights.”

People told us they mostly felt safe. Two people raised concerns about other people coming into their rooms which they felt uncomfortable with. We brought this to the attention of the registered manager for further investigation. Relatives felt the service helped to keep people safe, comments included, “I feel it is a safe place, [Person] has never shown, [I’ve] not noticed any anxiety at the place he lives”, “Well, [Person] is always happy at the home when we get out the of the car, he says I am home” and “We are really pleased with the care given and the way he is treated it is wonderful.”

There were shortfalls in the safeguarding processes which increased the risk of abusive practices occurring. The safeguarding incidents we reviewed had been escalated and reported to the local safeguarding adults’ team, however, a number had not been notified to CQC as required. This meant the provider’s policies and procedures had not been followed. There were ineffective processes in place to ensure people were protected from all forms of potential abuse. For example, care plans regarding false allegations had a stronger focus on protecting staff rather than ensuring people were confident to raise concerns. Care planning in relation to people’s finances needed to be more comprehensive to ensure it reduced the risk of financial abuse. We received mixed feedback from partners about how effective the systems and processes were to protect people from abuse. Concerns about the lack of collaborative working in response to safeguarding concerns was raised by 1 HCP who also expressed a lack of confidence in the management teams understanding over the need for unwitnessed falls resulting in injury needing to be escalated. However, a second HCP professional told us, “I do not recall any situations when safeguarding was not raised when it should have been”. The provider had policies and procedures in place to provide guidance to people and staff on the actions to take if they identified any abuse or had any concerns. Prior to our assessment, the provider had identified a need to refresh all the staff’s training in safeguarding. This training had been prioritised and delivered promptly. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The provider had applied for DoLS authorisations appropriately.

There was some evidence people were supported to understand and manage risks. One person told us how the service had responded in a balanced manner to help ensure they were not subject to restrictions put in place to keep another person as safe as possible. People and their relatives also felt the service worked hard to mitigate risks whilst also respecting people’s choices.

Staff were able to describe how they would respond to clinical risks such as choking. However, feedback from staff did not always indicate they had a shared understanding of people’s needs. We have talked about this further in the processes section of this quality statement.

The homes general risk assessment detailed laundry and cleaning products should be stored in a secure cupboard. However, we observed detergents freely accessible to people in the laundry room. The risk assessment did not adequately detail what the risk of this was for people and what action was needed to mitigate risks.

The systems and processes in place did not assess or mitigate risks effectively. Two people required a modified diet for safety. Their care plans gave conflicting information about this which increased the risk of the being offered inappropriate foods. The care plan did not reflect the most recent speech and language therapy guidance. Staff were aware of peoples correct dietary needs, but we were concerned this was due to less robust, informal sharing of information between staff rather than the care records containing accurate information about people’s clinical risks. Risks associated with health conditions such as diabetes and Huntington’s had not been adequately assessed and planned for. There needed to be a more robust system for assessing and mitigating people’s risk of falls. Moving and handling plans lacked detail and clarity. When staff were asked to describe how they supported 1 person with moving and handling tasks, they all gave slightly different answers. Information about allergies was not recorded in a consistent manner. Smoking risk assessments were not in place for all those who needed one. The provider’s environmental risk assessment lacked detail and did not effectively explore how risks such as the safety of those subject to a deprivation of liberty safeguards authorisation (DoLs) was to be managed when the home was not maintained as a secure environment. We received mixed feedback from healthcare professionals about the effectiveness of the systems and processes in place for how risks were assessed and planned for. One HCP raised concerns about the lack of detail in risk assessments and information about how these were to be mitigated whilst another felt the team had worked well to manage complex needs whilst ensuring risks were managed effectively. People’s freedom was restricted only when necessary and the registered manager promoted a positive risk taking approach in supporting people.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

People reported that overall, there were usually enough staff, that knew them well, available to meet their needs. One person said, “They have a scheduled member of staff, but it depends if they turn up this can lead to staff shortages this impacts on the service, but they probably meet the right staff criteria…I have a keyworker it is always the same person they discuss the care I want with me.” Relatives were positive about staffing levels but also about the skills of staff. Comments included, “It looks like they have staff at all times and are looked after very well by the staff excellent service…The staff are really excellent” and “Yes, I think there are enough staff, allocation and ratio are very good and meets the needs that are necessary.”

We did not observe any concerns in relation to staffing levels. People appeared to be in receipt of their 1:1 support and we observed positive interactions between people and staff. People were observed to eat when they wanted to, and staff were available to support this. People also appeared comfortable and confident to approach the registered manager and deputy manager when they needed to.

The provider operated recruitment processes which were robust and safe. Their recruitment practices were in line with best guidance and complied with relevant legislation. Overall, staff received training appropriate and relevant to their role, this included training in areas such as learning disability and autism and mental health. Staff completed an onsite induction on day 1 that covered a range of practical arrangements. Staff then also completed a 2 day induction, delivered by the provider’s training and quality assurance manager. This was mapped to Care Certificate standards. The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. It is made up of the 15 minimum standards that should form part of a robust induction programme. Staff received supervision every 2 to 3 months. The records of these sessions were brief, but overall indicated staff felt supported and that there was a positive culture within the service. There were systems in place to check the competency of staff to deliver particular tasks and development programmes for each staff role to support ongoing personal development, completion of these was, however, sporadic and needed to be further embedded.

Overall staff reported appropriate staffing levels. Comments included, “Yes generally [Enough staff] sometimes if people want to go out that can leave us short” and “Yesterday was difficult as there was 6 and 1 had to go home ill, but never been on a shift where people's needs are not met. There are 7 generally sometimes 8 if someone is going out. We try to plan it ahead” and “Most of the time ok, sometime maybe not enough, can't always meet the spontaneous requests to go out. But we always make a plan.” Staff told us they received the support they needed to perform their role. This included supervision. One staff member said supervision was “Quite regular, very helpful.” They told us how they discussed issues such as whether they had identified the right trigger for a behaviour. Staff reported they received training relevant to their role. For example, 1 staff member said, “Training, its generally ok, anything you feel you need, [Training manager] will put together a course to cover that specific area”. Staff were confident the registered manager had the skills, knowledge and experience to perform their role. Staff also spoke positively about the deputy manager. Comments included, “[Registered manager] is a good leader” and “[Registered manager] he cares about the residents, they are not just a commodity, they are people” and “You get a balance between [registered manager] and [deputy manager], she is a bit more sensitive and in touch, the balance is very good. [Deputy manager] is like a mother to us, but very professional. You understand what [Registered manager] wants for the home, there are a lot of new staff and he has managed to teach them and train them. I don’t think people leave because of him, he is good for the home.” The provider told us about the processes in place to monitor staff training to ensure compliance. There were development programmes in place for each role to support personal development and progression for staff.

Many areas of the home appeared clean, odourless and tidy. However, we observed some areas of the home were not clean or sufficiently maintained to allow these to be effectively cleaned. For example, some of the flooring, fixtures and fittings in the residents kitchen. This had been a concern when we last inspected in November 2021. Staff were observed to be using PPE appropriately.

Staff reported the premises were kept clean and hygienic. The registered manager was aware of how to access relevant guidance from external appropriate sources to support best practice within the service. The registered manager told us they had improved infection control by putting personal protective equipment (PPE) in the corridors to make it more accessible and convenient for staff. The registered manager and deputy manager told us they carried out observations to check staff were wearing and using PPE appropriately.

Systems and processes were not fully effective at managing the risk of infection. A weekly environmental audit was completed. This looked at whether the home was clean, in good decorative order, and furniture and fittings were in good condition, however, an audit completed 2 weeks before our visit raised no concerns and therefore had not been effective at identifying all of the areas where improvements could be made. Cleaning schedules were in place but not always fully completed. The provider’s general risk assessment lacked detail and was not an effective tool for predicting and mitigating infection control risks such as the actions staff should take in the event of spillages of bodily fluids for example. The records relating to training updates for staff in infection prevention and control gave conflicting information, with the summary records giving a completion figure of 100% for this training, but the individual records for staff members not showing this training had been completed.

People expressed no concerns about the cleanliness of the environment. Relatives told us they felt the home was kept clean and tidy, for example, 1 family member said, “The home is clean throughout, [Person’s] room is clean and well maintained the bathroom is adequate for their needs.”

The systems and processes in place did not ensure the safe management of medicines or the effective implementation of improvements. We continued to find similar concerns to those we identified during our last inspection in November 2021 and those raised in an audit of medicines safety undertaken by the ICB, despite the action plan for the audit stating most of the actions had been completed. For example, we continued to find concerns with the temperature monitoring of medicines, protocols for ‘when required’ (PRN) or variable dose medicines and with the disposal of medicines. When staff administered variable dose medicines, they were not recording the actual number administered in line with best practice. One person was prescribed 3 PRN pain relief medicines, however their PRN protocols lacked information about when to use which medicine and whether the medicines could be used in combination. Two non-administered tablets were in the medicines trolley 1 of unknown origin and 1 from 1 December 2023. A verbal instruction from a prescriber had not been confirmed in writing. These shortfalls increased the risk of medicine errors occurring. The systems and processes did not always support people to be involved in decisions about their medicines. For example, there was no evidence PRN protocols were co-produced with people. Feedback from partners raised concerns about the effectiveness of the systems and processes to ensure medicines were administered safely. Two healthcare professionals raised concerns about the method with which liquid medicines were being measured ready for administration as this was not in line with best practice. They explained that staff were ‘free pouring’ complex mental health medicines into pots rather than using an oral syringe to accurately measure the medicine. Another HCP raised concerns about the management of hyperglycaemia, training for staff on insulin administration and the completeness of the medicines policy.

Feedback from staff indicated there was a culture of not overusing medicines to control behaviour. For example, 1 staff member said, “[Person] he will request it, he recognises he is going downhill…. [Person] is generally very placid, certain things trigger him, slamming doors, again not a reason to give PRN, more when he starts to become aggressive to others.”

People told us they were involved in some decisions about their medicines. For example, 1 person told us, “I order my own prescriptions independently and then hand them over to staff they administer them at the right time…I administer my insulin injection which is given to me by the staff…Medication is locked away for safety purposes and stored accordingly to the policy at the home.” Feedback from relatives was mixed with 1 saying, “There has been a couple of mistakes over a period of time, when he came home on leave once, they gave me the wrong medication I always check before giving the medication at home” but another sharing, “The medication as far as I know is correct when on home leave the staff seems to know what they are doing.”