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Inspection Summary

Overall summary & rating


Updated 25 July 2018

We undertook an unannounced inspection of Chesham Bois Manor on 31 May 2018.

Chesham Bois Manor is a care home which is owned by B&M investments Limited. It provides care for up to 48 older people with a variety of physical disabilities and mental health issues. At the time of the inspection there were 37 people living at the home. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At our last inspection in December 2016 we found breaches of Regulations 11 and 12 Health and Social Care Act (Regulated Activities) Regulations 2014 and Regulation 18 Care Quality Commission (Registration) Regulations 2009. These related to the service not always working to the principles of the Mental Capacity Act 2005, risks and emergency evacuation plans not always being appropriately managed and not ensuring all required notifications were made to the Care Quality Commission (CQC). At this inspection we found action had been taken and improvements made.

Staff worked to the core principles of the Mental Capacity Act (MCA) 2005. Mental capacity assessments had been conducted and people were supported to make decisions.

Risks to people’s safety were well managed. Risk assessments were carried out and promoted positive risk taking, which enable people to live their lives as they chose. Personal emergency evacuation plans (PEEPS) were in place, accurate and up to date.

The service submitted appropriate and timely notifications. A notification is information about important events which the provider is required to tell us about in law.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. On the day of our inspection the registered manager was on annual leave. The service was being led by the deputy manager.

Staff supported people with kindness and compassion and went the extra mile to provide support at a personal level. Staff knew people well and many referred to them as family. Staff respected people as individuals and treated them with dignity whilst providing a high level of emotional support. People and their relatives, were fully involved in decisions about their care needs and the support they required to meet those individual needs.

People were positive about the food and told us they enjoyed the meals. Where people had specific dietary needs, these were met.

People were safe living in the home. There were sufficient staff to meet people's needs and staff had time to spend with people. The service had safe, robust recruitment procedures to ensure staff were safe to work with vulnerable people. People received their medicines safely.

People received effective care from staff who had the skills and knowledge to support them and meet their needs. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the procedures in the service supported this practice. People were supported to access health professionals when needed and staff worked closely with people's GPs to ensure their health and well-being was monitored.

People had access to information about their care and staff supported people in their preferred method of communication.

The service was responsive to people's needs and ensured people were supported in a personalised way. People's changing needs were responded to promptly. People had access to a variety of activities that met their individual needs.

The registered manager monitored the quality of the service and looked for continuous improvement. There was a cle

Inspection areas



Updated 25 July 2018

The service was safe.

There were sufficient staff deployed to meet people�s needs.

People told us they felt safe.

Staff knew how to identify and raise concerns if they suspected abuse.

Risks to people were managed and assessments were in place to manage the risk and keep people safe.



Updated 25 July 2018

The service was effective.

People were supported by staff that had the skills, training and knowledge to support them effectively.

Staff received support and supervision and had access to further training and development.

Staff had been trained in the Mental Capacity Act 2005 (MCA) and understood and applied its principles.



Updated 25 July 2018

The service was caring.

Staff were kind, compassionate and respectful and treated people and their relatives with dignity and respect.

Staff understood people's individual needs and people were cared for in a kind, caring and respectful way.

People were supported to maintain their independence and were given the information, support and equipment they needed.



Updated 25 July 2018

The service was responsive.

People's records were up to date and reflected their needs, wishes and interests.

People's needs were assessed and personalised care plans were written to identify how people's needs would be met.

People's wishes about End of Life care were documented



Updated 25 July 2018

The service was well led.

The service notified CQC of reportable events

The registered manager had developed positive relationships with the staff team, relatives and people who lived at the service.

The service had systems in place to monitor the quality of service.

The quality of the service was regularly reviewed. The registered manager continually strived to improve the quality of service offered.