CQC report explained · a residential care home
What the CQC found at Bonhomie Sarisbury Green
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2022
Rated Requires Improvement; inspectors found kind and responsive care, but medicines, staff training, care records and oversight were not consistently safe or effective.
This was an unannounced inspection on 23 and 24 November 2021. Inspectors spoke with five people, seven staff and three health and social care professionals. They reviewed care, medicines, recruitment, training and management records.
The home was rated Requires Improvement overall. Safe, Effective and Well-led were rated Requires Improvement. Caring and Responsive were rated Good.
Inspectors found medicines records that were incomplete or incorrect. They also found poorly maintained areas, unclear risk information, long care plans, gaps in staff knowledge and some care advice that was not followed. The manager acted on some issues during the inspection, including removing freely available alcohol gel and arranging maintenance work.
The home was in breach of Regulation 12 because medicines records lacked accuracy and detail and placed people at risk of harm. CQC said it would request an action plan, continue monitoring and return for a reinspection.
Kind staff
Staff were generally kind and knew people's backgrounds, preferences and family information. Inspectors saw positive interactions between staff and people.
“Staff were kind to people, and we saw positive interactions between staff and people.” from the report
Personalised support
Care plans included people's wishes, routines, preferred activities and communication needs. People had individual activity plans based on their interests.
“People had care plans that detailed how their needs and wishes would be met.” from the report
Working with professionals
The home had positive links with health and social care professionals and worked with them on people's support and independence.
“The provider had positive links with health and social care professionals and both worked collaboratively with them to ensure people were receiving the correct support.” from the report
Food choices
Meals looked appetising, portions were generous and different textures and diets were provided. Snacks and drinks were also available.
“Meals looked and smelled appetising and people were given large portions.” from the report
Medicines records
seriousSome medicines records were incomplete or wrong. This included unclear instructions and a medicine recorded as needed when it had not been prescribed that way.
“We found no evidence that any one had been harmed however records of medicines administration lacked accuracy and detail.” from the report
Swallowing advice
seriousInspectors found that current speech and language therapy advice about food texture was not being followed. They said this could have caused harm through food entering the person's airway.
“We saw advice was not always followed, the section on nutrition details an example where SaLT advice was not fully followed.” from the report
Staff skills
needs fixingInspectors were not assured that all staff could respond correctly to choking. Mental health training was limited, and there was no recent training about some specific medical conditions.
“We were concerned about staff knowledge of first aid.” from the report
- 01What changes have you made to medicines records, especially for high-risk and as-needed medicines?
- 02How do you now check that staff follow speech and language therapy advice about food textures?
- 03What training and competency checks have staff completed for choking, mental health needs and the medical conditions people live with?
- 04How have you shortened and clarified care plans and made sure risk assessments contain clear actions?
- 05What maintenance and cleaning work has been completed since the inspection, and how do you check that it remains effective?
This was the first comprehensive inspection of the newly registered service and covered all five CQC questions, including infection prevention and control under Safe. This explanation was written from the published report of 19 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2020
Bonhomie Sarisbury Green was inspected but not rated; earlier food-safety failures had been addressed, but this was not a full service rating.
This was a targeted inspection on 24 September 2020. It followed concerns about food safety, maintenance, risk management and behaviour that others found challenging. One inspector visited the kitchen and spoke with the manager, provider representative and chef. The CQC also sought views from staff, relatives, local professionals and the local authority.
Environmental Health had previously found serious problems with food storage, cleaning, infection control, kitchen maintenance and records. By the inspection, hot water had been restored, the kitchen had been cleaned, food was separated, and temperature checks and cleaning schedules were in place. Inspectors found these improvements had been maintained.
The report also says suitable risk plans were in place and healthcare professionals had been contacted when needed. A person whose behaviour had caused concern had moved to a more suitable setting. The service was inspected but not rated, because this visit only looked at specific concerns. All five areas will be assessed at the next comprehensive inspection.
Food safety improvements
The kitchen had been cleaned and reorganised. Food was labelled, dated and stored safely, with temperature checks and cleaning schedules in place.
“We found recommendations from the Food Standards Agency (FSA) had been implemented and sustained.” from the report
Risk planning
The report says suitable plans were in place to reduce risks. Staff had guidance on how to respond when behaviour became challenging.
“Care plans were detailed and contained useful guidance for staff to follow when behaviours challenged others.” from the report
Healthcare links
The manager contacted relevant healthcare services when a person's needs and behaviour caused concern. Investigations and safeguarding referrals were also made.
“Records demonstrated the registered manager had contacted the relevant healthcare agencies to request support for the person concerned.” from the report
Relatives' views
Relatives who gave feedback described the care and staff positively, and said the manager was available to help.
“We are very happy with everything, the staff are all very helpful and the manager is always available and willing to assist in any way.” from the report
Serious earlier kitchen problems
seriousBefore the inspection, Environmental Health found widespread problems with food storage, infection control, kitchen maintenance and records. Inspectors found that these issues had been addressed by the time of their visit, but families may want to check that the improvements have continued.
“They reported to us widespread and significant failings in respect of food storage, poor infection control procedures, poor kitchen maintenance and recording concerns.” from the report
Audits had not been followed through
needs fixingThe provider acknowledged that earlier audits were not strong enough to identify and resolve the problems promptly. New cleaning schedules and checks had since been introduced.
“Audits were not being followed through, they weren't as robust as they should have been.” from the report
- 01How are food temperatures, food dates, cleaning and kitchen maintenance checked now?
- 02Who reviews the cleaning records and what happens if a check is missed?
- 03How are care plans and behaviour support guidance kept up to date for each resident?
- 04How are healthcare professionals involved when a resident's behaviour or mental health needs change?
- 05When was the last comprehensive inspection, or when is the next one expected?
This was a targeted inspection of specific concerns about risk management and food safety; all five key questions will be assessed at the next comprehensive inspection. This explanation was written from the published report of 2 December 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bonhomie Sarisbury Green
Each visit the CQC has published, newest first, back to the day the home was registered.
- February 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- January 2019
Registered with the Care Quality Commission on 11 January 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
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