Surbiton Care Home

Updated 28 January 2023

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

This inspection was carried out by one inspector.

Service and service type

Surbiton Care Home is a ‘care home’. 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. Surbiton Care Home 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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

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 (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 reviewed information about important events. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people living at the home and 1 visiting relative. We spoke with 2 care staff, the registered manager and the regional director. We reviewed the care records and medicines administration records (MAR) for 3 people. We reviewed 3 staff recruitment files. We looked at a range of documents in relation to the management of the service such as polices, audits and premises documentation. After the inspection we received feedback from 3 relatives.

Updated 28 January 2023

About the service

Surbiton Care Home is a residential care home providing personal care to up to 26 people. The service provides support to older people and those with dementia. At the time of our inspection there were 17 people using the service.

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

Risk management was not always clearly recorded to ensure staff had guidance to mitigate the likelihood of risk occurrence. Where potential incidents had occurred, these had not always been identified, reported or investigated. Management and oversight of the service required some improvement to ensure audits were effective in driving improvements.

There were enough staff to meet people’s needs, and despite the lack of written guidance staff knew how to respond to people’s needs. People received their medicines when they needed them. Staff understood how to safeguard people from the risk of abuse.

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.

People, relatives and staff were complimentary of the registered manager and the support and passion they brought to the role. The service worked in partnership with other agencies to meet people’s needs.

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

Rating at last inspection

The last rating for this service was good (published 30 January 2018).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

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.

Enforcement and Recommendations

We have identified a breach in relation good governance at this inspection.

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.