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We are carrying out a review of quality at Surbiton. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 21 November 2019

About the service

Surbiton is a is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to older adults.

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

People did not receive care and support from a service that was well-led. The registered manager was not a visible presence at the service. There were on-going systematic failings in the oversight and management of the service. Audits did not always identify issues found at the inspection, identified actions were not always followed through.

People did not receive a service that was safe. People’s medicines were not managed safely. The provider had failed to ensure robust recruitment procedures were in place to ensure suitable staff members were deployed. People did not receive timely care as the provider failed to adequately deploy staff. The provider failed to ensure staff members did not work in excess of the restrictions placed on their student visas. Risk management plans were not comprehensive and did not always give staff clear guidance to mitigate identified risks. The provider failed to learn lessons when things went wrong.

People did not always receive care and support from staff that underwent training to enhance their skills and experiences. Training records confirmed staff training was not up-to-date with no pre-booked training to rectify this. People did not always receive care and support from staff that had undergone an induction or reflected on their working practice through regular supervision and annual appraisals. People’s fluid and food intake was not monitored effectively and care plans did not clearly detail people’s preferences. Pre-admission assessments were not as comprehensive as they could be.

People’s end of life wishes were not always documented and when they were, they were not comprehensive. Care plans were not as person-centred as they could be.

The provider failed to continue to ensure continued learning and failed to drive improvements.

People were protected against abuse as staff had sufficient knowledge on how to identify, respond to and escalate suspected abuse. People continued to be protected against the risk of cross contamination as staff had access to sufficient amounts of personal protective equipment.

People’s health and well-being was monitored, where concerns were identified healthcare services were notified.

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 told us they received care and support from staff that were kind and supportive. People’s privacy was respected, and their dignity encouraged and maintained. People continued to be encouraged to share their views on the care provided. Staff were aware of the importance of encouraging people to maintain their independence and did so where possible.

People’s communication needs were met. The provider had an Accessible Information Standard policy in place which staff were familiar with. Complaints were investigated and responded to in a timely manner.

People were encouraged to share their views with the service. The provider sought partnership working to improve the service, records confirmed this.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Requires Improvement (published 1 May 2019) and there were multiple breaches of regulation. This service has been rated Requires Improvement for two consecutive inspections. 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 made and the provider was still in breach of regulations.

Why we inspected

This was a plann

Inspection areas



Updated 21 November 2019

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 21 November 2019

The service was not always effective.

Details are in our effective findings below.



Updated 21 November 2019

The service was caring.

Details are in our caring findings below.


Requires improvement

Updated 21 November 2019

The service was not always responsive.

Details are in our responsive findings below.



Updated 21 November 2019

The service was not well-led.

Details are in our well-Led findings below.