We completed an unannounced inspection at Chiltern Rest Home on 7 March 2017. This was the first rating inspection since the provider changed their registration with us on 8 November 2016. We carried out this inspection to assess whether the provider was meeting the required standards of care.

Chiltern Rest Home are registered to provide accommodation with personal care for up to 21 people. People who use the service may have physical disabilities and/or mental health needs such as dementia. At the time of the inspection the service supported 19 people.

There was a registered manager at the service. 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.

We found that improvements were needed to ensure that effective systems were in place to consistently maintain care records that were accurate and up to date. When care records are not accurate and up to date, people are placed at risk of receiving inconsistent or unsuitable care.

People felt safe when they were supported. Staff understood how to recognise possible signs of abuse and the actions they needed to take if they had any concerns.

People’s risks were assessed and managed to keep people safe from harm.

There were enough suitably qualified staff available to keep people safe and the provider had a safe recruitment procedure in place.

Medicines were administered in a safe way. There were systems were in place to ensure people were protected from risks associated with medicines management.

People were supported by staff who had received training, which gave staff the knowledge and skills to provide appropriate care that met people’s needs.

People consented to their care where able and the provider followed the requirements of the Mental Capacity Act 2005 (MCA) where people lacked the capacity to make certain decisions about their care. Staff understood their responsibilities and followed the requirements of the MCA when they provided support.

People told us that they enjoyed the food. Where people were at risk of malnutrition and/or dehydration monitoring was in place to ensure people were eating and drinking sufficient amounts to keep them healthy.

People were supported to access health professionals in a timely manner to maintain their health and wellbeing.

People were supported in a caring and compassionate way by staff who knew people well. People’s privacy and dignity was protected when staff provided support and staff promoted and listened to people’s choices in care.

People were involved in their care. People received care that met their preferences because staff knew people well and knew how they liked their care to be provided.

People were encouraged to be involved in meaningful hobbies and interests within the service to promote their emotional wellbeing.

The provider had a complaints policy available and people knew how to complain and who they needed to complain to.

There was an open and honest culture within the service and the registered manager was approachable to people, staff and professionals.

The registered manager was aware of their responsibilities and had informed us (CQC) of any notifiable incidents that had occurred at the service.

The registered manager had effective systems in place to assess, monitor and improve the quality of care. Plans were in place to ensure improvements to the service were continually reviewed and changes were made where needed.