Background to this inspection
Updated
10 November 2023
Inspection team
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.
Inspection team
The inspection was carried out by two inspectors, one of whom was a bank inspector, an Expert by Experience and a specialist professional advisor. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
The specialist professional advisor worked as a nurse in the care of older people.
Service and service type
Surbitonian Gardens is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and we looked at both during this inspection.
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 a manager in post who was in the process of registering with the CQC. However, shortly after our site visit they left the service.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We used the information the provider sent us in the provider information return. 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 also reviewed the information we held about the service and obtained feedback from a member of the local authority.
We used all of this information to plan our inspection.
During the inspection
Inspection activity started on 24 August 2023 and ended on 10 October 2023. We visited the service location on 24 August 2023 and 7 September 2023. 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 spoke with the deputy manager, registered manager, the head of care, 4 nurses, 4 care workers, 3 team leaders, a member of the domestic team, the chef and activities coordinator as part of our inspection. We also spoke with 3 people using the service and 21 of their relatives. We reviewed 7 care records, medicines administration records (“MARs”), recruitment records and other records related to the management of the service.
Updated
10 November 2023
About the service
Surbitonian Gardens is a residential care home providing personal care to up to 80 people. The service provides support to older people with nursing needs and those with dementia. At the time of our inspection there were 50 people using the service.
People’s experience of using this service and what we found
People and their relatives gave positive feedback about the staff and told us they were kind and caring. We observed positive interactions between people and staff throughout the inspection.
The provider had clear risk assessments in place and their care plans included clear guidelines for staff in how to mitigate risks to people’s safety in areas of known risk.
We were assured that this service met good infection prevention and control guidelines. The provider facilitated safe visiting arrangements, had systems in place to ensure the building was clean and had systems in place to prevent the spread of infection.
There were safe systems in place for the management and administration of medicines. Staff had received training and were clear about their responsibilities. The provider supported people with their nutritional needs.
The provider carried out appropriate pre- employment checks before hiring staff. There was an induction programme for new staff, which prepared them for their role. Staff were provided with enough training and supervisions to help them carry out their duties. There were enough staff employed to meet people’s needs, although the provider was working towards hiring a greater proportion of permanent as opposed to agency staff.
The provider adapted the service with people’s needs in mind and assisted them to participate in activities and avoid social isolation. Where people required support at the end of their life, this was provided in a compassionate and dignified way. People’s complaints were responded to in a timely manner in accordance with the provider’s policy.
Staff gave good feedback about the registered manager who was in post at the time of the inspection. However, people’s relatives expressed concern as the registered manager left shortly after our site visit. We spoke with the acting manager who was the deputy manager at the time of our site visit and she confirmed she would continue to provide management cover.
The provider monitored the quality of people’s care, and took action where any issues were identified.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk
Rating at last inspection and update
This service was registered with us on 27 July 2022 and this is the first inspection.
Why we inspected
The inspection was prompted in part due to concerns received about staffing. A decision was made for us to inspect and examine those risks.
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.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.