Chesham Bois Manor

Updated 22 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector over two days with an Expert by Experience on site on day two of the inspection. A second Expert by Experience carried out calls to relatives after the inspection.

An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service

Service and service type

Chesham Bois Manor is a ‘care home’ without nursing. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Chesham Bois Manor is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. A manager was managing the service. However, they were leaving the service In July 2022 with the Head of Governance taking on that role to give the provider the time to recruit a suitable manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with fourteen people who used the service and two relatives about their experience of the care provided. We spoke with eight staff including the manager, deputy manager, assistant manager, operations manager, senior administrator, senior carer, carer and head of housekeeping.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records which included, multiple medicine records, five staff recruitment files, supervision and training records. A variety of records relating to the management of the service, including health and safety, audits and cleaning schedules were reviewed, and other records were requested.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at policies, eight electronic care plans, meeting minutes, training data and quality assurance records. We spoke with five relatives and received written feedback from a further three relatives.

Updated 22 July 2022

About the service

Chesham Bois Manor is a residential care home providing accommodation and personal care to up to 48 people. The service provides support to older people, including people with dementia. At the time of our inspection there were 35 people using the service.

Chesham Bois Manor accommodates people across three units, with two of the units providing care to people living with dementia. The service has a mix of bedrooms with en-suite facilities and other bedrooms where people access the communal bath/ shower facilities. Each unit has its own communal lounge and dining area. The service is set in well-maintained grounds with a secure outside area for people to access.

People’s experience of using this service and what we found

People and relatives were generally happy with their care. People told us they felt safe and described carers as “Kind, caring and obliging.”

Relatives told us they were happy with their family members care and that most people had good access to health care professionals. They felt the service had improved with regular better trained staff. They commented “[Managers name] and their team are doing a superb job and you can tell they really do care with everything they do,” “Care is good and attentive. There is attention to detail,” and “Family member has lived in this home for some time now. I think that the home is looking after them well and I think things have been improving. The staff seem happier and are all pulling together better.”

A number of relatives felt communication with them and activities available to their family member needed to improve. A second engagement lead had recently been appointed with the aim to develop activities.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The provider had been proactive in recruiting staff to provide consistent care to people. Staffing levels had improved and were sufficient, with agency use decreased. Staff told us the training provided had improved, however key training was overdue and competency assessments were incomplete and others unavailable.

Auditing and monitoring of the service was taking place which showed the provider had identified, shortfalls in the service provided. Improvements had been made to records, however further improvements were required to ensure records were accessible, accurate and suitably maintained.

Most risks to people were identified and mitigated, with staff aware of people’s risks and how to support them. Where risks were not mitigated this was immediately addressed. Safe medicine practices were promoted.

Systems were in place to safeguard people with evidence of learning from incidents to prevent reoccurrence and safeguard people.

People’s nutritional and hydration needs were identified, monitored and action taken where records did not evidence people had the required food and fluid.

The manager had been proactive in making improvements to the service, which included creating a more positive culture which promoted positive outcomes for people.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was inadequate (published 13 January 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made, however further improvements were required to be fully compliant with the regulations reviewed.

The service had been in Special Measures since December 2021. During this inspection the provider demonstrated improvements have been made and their audits had identified the areas that still needed improving. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced focused inspection of this service on 9,10 and 17 November 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, safeguarding, recruitment, staffing, training, good governance and need for consent.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-Led which contained those requirements and warning notices.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well- Led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chesham Bois Manor on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified continued breaches in relation to training, consent and records at this inspection. However, in view of the progress made within the service we have taken a proportionate response to the continued breaches.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.