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Surbiton Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 9 April 2021

About the service

Surbiton is a domiciliary care agency. It provides personal care to older people living in their own houses and flats in the community. At the time of the inspection, there were seven people receiving the regulated activity personal care.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.

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

People did not always receive medicines in line with good practice. Medicine administration records were not always completed appropriately. The deployment of staff did not always ensure staff had adequate time off.

Records were not always completed appropriately and there were instances of the wrong name being recorded in people’s documents. Audits did not always identify the issues found during this inspection.

Systems were in place to protect people from abuse. Pre-employment checks were carried out prior to staff commencing to ensure they were suitable for the role. Accidents and incidents were monitored, and action taken to minimise repeat incidents. Infection prevention and control (IPC) measures were in place.

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 were supported to access healthcare services when appropriate. People received care and support from staff who underwent training to enhance their knowledge. Staff were supported to undertake an induction on commencing their role and had their competencies assessed. Where agreed in people’s care package, people were supported to access food and drink that met their dietary requirements and preferences.

People continued to be supported by staff that treated them with respect and encouraged their independence where safe to do so. People’s diverse needs were embraced. Relatives confirmed they were involved in the decision-making process and pre-admission assessments were robust.

There had been a significant change in the management of the service with the recruitment of a care consultant, which had made a positive impact on the running of the service. People’s relatives’ spoke positively about the new changes and confirmed they were happy with the level of care provided. Records confirmed the provider worked in partnership with stake holders. The provider sought to continuously improve.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at

Rating at last inspection

The last rating for this service was inadequate (published 15 June 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been sustained and the provider was still in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Surbiton on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this. We will continue to discharge our regulator

Inspection areas


Requires improvement

Updated 9 April 2021

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 9 April 2021

The service was not always effective.

Details are in our effective findings below.



Updated 9 April 2021

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 9 April 2021

The service was not always responsive.

Details are in our responsive findings below.



Updated 9 April 2021

The service was not well-led.

Details are in our well-Led findings below.