CQC report explained · a residential care home
What the CQC found at Chesham Bois Manor
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Most risks were identified and managed, and staffing, safeguarding, medicines and infection control had improved. Some risk assessments and recruitment records were still incomplete or needed more detail.
- Effective?
- Requires improvement
- People generally received suitable food, fluids and access to health professionals. However, mental capacity assessments were missing for several decisions, and staff training and competency checks were not consistently recorded or completed.
- Caring?
- Good
- This question was not inspected during this focused visit. The rating from the previous inspection was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. The rating from the previous inspection was used when calculating the overall rating.
- Well-led?
- Requires improvement
- Management had improved the culture, communication and monitoring of the home. However, records, training information, supervision records and cleaning records were not always properly maintained, and there was no registered manager in post.
What inspectors found, July 2022
Rated Requires Improvement; the home had improved and left special measures, but consent, training and records still fell short.
Inspectors made an unannounced focused inspection visit on 21 and 22 June 2022. They spoke with people, relatives and staff, observed care and reviewed medicines, care plans, recruitment, training and management records.
The home had improved from its previous Inadequate rating. Staffing levels were better, agency use had reduced, safeguarding systems had improved, and medicines, food and fluids were generally managed safely. People and relatives were mostly positive about the care and staff.
Important problems remained. Mental capacity assessments were missing for some decisions, training and competency records were incomplete, and care and management records were not always accurate or up to date. The home was rated Requires Improvement for Safe, Effective and Well-led.
The home had been in Special Measures since December 2021, but it is no longer in Special Measures because it was no longer rated Inadequate. The CQC required an action plan and said it would continue to monitor progress.
Better staffing
Staffing levels had improved and agency use had reduced, which supported more consistent care.
“Since the last inspection there had been a high turnover of staff, with new staff recruited which had resulted in a reduction of agency use.” from the report
Safeguarding improved
The home had strengthened safeguarding training, reporting and work with outside agencies.
“The service had improved multi-disciplinary working with outside agencies, and they had provided training to relatives to raise awareness of safeguarding.” from the report
Medicines managed safely
Inspectors found suitable storage, administration records and checks for medicines.
“The medicine administration records viewed showed medicine was given as prescribed and systems were in place to audit medicines to ensure stock checks were maintained and accurate.” from the report
Positive management changes
The manager had worked to improve the culture, communication and response to poor practice.
“The manager had worked hard to change and improve the culture within the service.” from the report
Food and fluids monitored
People's nutritional needs were assessed, with weight and fluid intake monitored and action taken when records showed shortfalls.
“People's nutritional and hydration needs were identified, and measures were in place to ensure they were met.” from the report
Consent decisions
seriousMental capacity assessments were missing for several decisions, including CCTV, medicines, COVID-19 testing and restrictions. This was a continued breach of Regulation 11.
“Not enough improvement had been made at this inspection and the provider was still in breach of regulation 11.” from the report
Training and competency checks
seriousTraining records showed gaps, and competency assessments were incomplete or unavailable. This was a continued breach of Regulation 18.
“The training matrix provided showed gaps in training and a low percentage of training for medicine administration, infection control and behaviours that challenge.” from the report
Care and management records
seriousSome records were contradictory, incomplete or not filed promptly. This included care plans, training records, supervision records and cleaning records, and was a continued breach of Regulation 17.
“Some people's files were contradictory or incomplete.” from the report
Activities
needs fixingPeople and relatives said there were too few activities and not enough stimulation. A second engagement lead had been appointed, but improvements were still expected.
“People and their relatives did not feel the current activities available was stimulating or sufficient.” from the report
- 01How do you complete and review mental capacity assessments for decisions about medicines, CCTV, testing and restrictions?
- 02Which staff training is currently overdue, and how do you check that staff are competent before working independently?
- 03How do you make sure care plans and daily records are accurate, consistent and updated when people's needs change?
- 04What activities are now available each week, including for people living with dementia?
- 05Who is currently managing the home, and how can relatives contact them and receive a response?
This was an unannounced focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 22 July 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, January 2022
Chesham Bois Manor was rated Inadequate and placed in special measures because inspectors found unsafe care, poor staffing and weak management.
This was an unannounced inspection over three days in November 2021. Inspectors spoke with people, relatives and staff. They observed care and mealtimes, and checked care plans, medicine records, staff files, rotas and management records.
Inspectors found that people were not consistently protected from harm. Risks such as falls, pressure damage, abuse and poor nutrition were not managed properly. Some care was rushed or missed because there were not enough staff. Medicine systems were in place, but some records and instructions were incomplete.
The home was also rated Inadequate for effective care and management. People's food and drink needs were not reliably met, staff training and supervision were incomplete, and the Mental Capacity Act was not followed properly. Management checks had failed to identify or correct important problems.
The overall rating fell from Good at the previous comprehensive inspection to Inadequate. The home was placed in special measures. The regulator required an action plan, served warning notices for four regulations and said it would monitor progress and reinspect.
People felt safe
People told inspectors they felt safe, and relatives gave examples of safety equipment being provided.
“People told us they felt safe.” from the report
Access to health professionals
People had access to GP services and other health professionals. Relatives said they were kept informed about changes in health and welfare.
“People had access to other health professionals such as GP services, chiropody and dentist.” from the report
Food choices
The home offered a varied menu, two choices and specialist diets. People and relatives said they were happy with the food, although support at mealtimes was poor.
“People were provided with a varied menu and provided with two meal choices.” from the report
Building and outdoor space
The home was maintained and had dementia-friendly displays, signs, handrails, lifts and a secure outdoor area.
“The service had large well-maintained gardens.” from the report
People were not always safeguarded
seriousIncidents of aggression and other possible safeguarding concerns were not always reported or investigated. Inspectors also saw a person at risk of malnutrition not being offered food or drink at lunchtime.
“People were not safeguarded from the risk of abuse.” from the report
Risks were not managed
seriousInspectors found missing or inadequate risk assessments, missed repositioning, unsafe footwear and other hazards. One person was not repositioned for nearly eight hours despite a care plan requiring two-hourly repositioning.
“Risk management was not effective in mitigating risks.” from the report
Insufficient staff
seriousRequired staffing levels were missed on many shifts. This led to rushed care, delayed meals and care being omitted.
“Sufficient numbers of staff were not provided.” from the report
Nutrition and hydration were missed
seriousSome people waited a long time for meals or drinks, were not supported to eat, or were not offered food and drink in their bedrooms. Weight checks were also missed despite weight loss.
“People's nutritional and hydration needs were not met.” from the report
Weak training and supervision
needs fixingTraining and induction records were incomplete, some medicine competency checks were overdue, and staff did not receive regular supervision.
“Staff were not suitably inducted, trained and supported in their roles.” from the report
Poor management oversight
seriousAudits and governance meetings failed to identify or act on repeated problems. Care, staffing, cleaning and health and safety records were incomplete or inaccurate.
“Good governance was not established, and records were not suitably maintained.” from the report
- 01What action has been taken to ensure there are enough suitably trained staff on every shift?
- 02How do you now check that people are offered meals and drinks promptly, including people eating in their bedrooms?
- 03How are repositioning, weight checks and other care tasks recorded and checked each day?
- 04What changes have been made to safeguarding reporting, risk assessments and learning from incidents?
- 05What was the outcome of the regulator's follow-up inspection and are any warning notices or special measures still in place?
This was a focused inspection prompted by concerns about nutrition, hydration and personal care; inspectors examined Safe, Effective and Well-led, while Caring and Responsive were not inspected and previous ratings were carried over. This explanation was written from the published report of 12 January 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.
Every inspection of Chesham Bois Manor
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- July 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2022InadequateSafe: InadequateEffective: InadequateWell-led: Inadequate
- February 2021Inspected but not ratedSafe: Inspected but not rated
- July 2018Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- May 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2014
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 6 May 2011.
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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