Surrey Heights

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question 'Good'. At this assessment the rating has changed to 'Inadequate'. This meant people were not safe and were at risk of avoidable harm. The service was in breach of 2 legal regulations in relation to safe care and treatment, people's medicines not always being managed and, safeguarding people from abuse and improper treatment.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.
Leaders and staff did not record incidents and accidents consistently. This contributed to lack of investigation to understand how people had been placed at risk of harm, and any learning to mitigate future risks to people.
There were repeated incidents of distress involving physical and verbal altercations between people and towards staff. Tools to monitor these risks were not being completed in full or analysed to understand the cause of the distress. The registered manager and team leaders did not update people’s risk assessments or care plans following incidents to mitigate the risk of reoccurrence.
For example, we found one person had been involved in 8 incidents of distressed behaviour within four weeks. These incidents resulted in physical harm to staff and other people. However, we found these incidents were not recorded in the provider’s incident log. This meant prompt action was not taken to minimise the risk of the concerns happening again.
The registered manager did not ensure there was a consistent process in place for recording and reviewing accidents and incidents and sharing learning with staff to ensure risks were mitigated and care plans were updated to reflect any changes in people’s individual needs. We reviewed people’s daily notes and identified incidents were not always recorded and monitored to identify learning outcomes to support people.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.
We identified examples where people’s needs with distress, nutrition and hydration were not always managed, supported or monitored to ensure people did not experience risk of harm or abuse. For example, we found one person’s care plan noted ‘if there are any issues with [persons] mental health it should be reported to the member of staff in charge’. This information did not clearly outline the processes and systems in place to ensure people would receive appropriate referrals, support and care when required. This did not evidence staff had effective guidance in place to ensure referrals were completed when required.
When people were admitted to the service, a care plan was not always available for staff to follow. The registered manager said, “Once [people] have come into the home, as time goes on, we get more information, involving them if we have any concerns, getting their feedback into the care plan.” One staff told us “Any new residents they tell us to read the printed care plan.”, “but some residents there are no care plan”, “We met a new person and no paperwork”. There was a risk people would not receive the support they needed due to the lack of up-to-date information in the care plans.
Daily records did not always contain details of visits from GP. Information in people’s care plans was not organised clearly and concisely. This was a risk that inaccurate information could be passed to other professionals should a person require to move between services, such as hospital admission. The local authority told us concerns were not always raised by the home itself. This did not demonstrate the provider had appropriate systems, processes and practices to safeguard people.
The registered manager told us they reviewed incoming referrals and completed needs assessments before admission. Handover sheets were in place, and we were able to see staff noted any upcoming appointments people were to attend. The registered manager told us how they worked with partnership services including GPs, occupational therapists, district nurses, Speech and Language Team (SaLT) and Mental Health teams to ‘reduce the risk to people’.
We sought feedback from partnership agencies. One professional told us the home had “good working relationship with community nurses”.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.
We reviewed people’s daily notes and found safeguarding incidents which were not reported to CQC or the relevant agencies without delay. For example, one person had a “wound red mark on [their] cheek from altercation with another resident”. The provider had not evidenced the local authority were informed, and what action was taken to prevent this type of incident from occurring again in the future.
We observed one person with a known risk of choking began coughing during their mealtime. We observed staff did not attend to the person at the time, and did not ensure they provided supervision during the person’s mealtime as instructed in their care plan. Staff did not demonstrate they were following individuals' care plans and risk assessments to safeguard them from the risk of avoidable harm. We raised this concern with the provider during the visit, and they subsequently carried out their own investigation.
The provider did not demonstrate they followed their policy when administration of people’s medicine was under or over-dosed. This did not ensure safeguarding processes were followed. We noted discrepancies on people’s medicine administration record (MAR) charts.We found discrepancies in the sedative medication stock counts for two individuals, which did not align with their prescribed doses or MAR charts. This indicated that the provider had not ensured medicines were administered and monitored safely, putting people at risk of receiving incorrect or unsafe dosages. The provider did report this to the Local Authority and the CQC once identified, and the provider implemented measures to reduce the risk of recurrence.
The registered manager told us “Safeguarding concerns are managed through feedback from staff, what was the incident, cause, could it be prevented.” Staff told us how they would report safeguarding concerns and were confident to raise safeguarding issues to managers and to use the whistleblowing process if needed. Despite the issues we identified around safeguarding processes, people and their relatives told us they felt safe in the home, and we observed staff being attentive to people when mobilising and during mealtimes.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Staff told us they did not always read people’s care plans and risk assessment. Despite having access to these records staff told us only the team leaders read care plans and risk assessments. This information was then relayed to the remaining care staff. This meant all staff responsible for supporting people did not independently take time to understand and review people’s information. This did not ensure they were able to apply knowledge of people’s care plans and risk assessments when delivering care. This did not demonstrate people’s risks were managed safely and effectively when supported by staff.
People’s care plans and risk assessments were not always clear about how to manage and mitigate risks, promote choices and ensure staff were guided to safely support people. We found some people’s care plans with diabetes did not contain any detailed information how to manage this condition, risks to their health and what to do in case of hypoglycaemia, hyperglycaemia or presenting unwell. We found one person with diabetes experienced ‘unwell’ symptoms, and their care plan advised to check their glucose if presenting ‘unwell’. There was no information how or if this person’s glucose was monitored, how frequently and by who.
We reviewed people’s daily notes and identified one person had diagnosis of seizures, with an episode of seizure activity within the past year.This person’s care plan did not contain any information about their seizures or type of epilepsy. This did not ensure staff could quickly and easily identify this person’s condition and could recognise how to manage and support this person in the event of a seizure. We raised these concerns with the provider. The provider took prompt action to resolve this following the inspection.
The provider did not ensure people’s care was provided in line with the risks identified in their care plans and risk assessments. We observed some people climbing stairs independently without appropriate footwear or support from staff. Their care plan stated they were at high risk of falls and when mobilising they needed to be “closely monitored and supported”.
Another person required wellbeing checks every 30 minutes during the night, and support with repositioning. However, their daily notes did not evidence either of these were completed in line with their assessed needs.
We found one person’s care plan noted they were not smoking at present; however, their daily notes evidenced they were actively smoking. This person was also using paraffin-based emollient products which are highly flammable. The provider did not evidence relevant risk assessments were completed regularly, and the risk of harm to this person was monitored and managed.
The provider did not have an effective system in place to assess and review risks to the health and safety of people to ensure staff were following plans of care and risk assessments consistently. Lack of oversight did not always ensure sufficient action had been taken to mitigate identified risks.
Relatives and people were positive about the support and care people received. The registered manager told us they spoke to families and residents; “involving them as much as you can to make them aware what the risk could be”.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.
We observed corridors did not have handrails or seating to support people when walking. The registered manager told us, “Residents are assessed on the rooms we have available, if it would meet their needs”. However, we observed some people’s rooms were located at the very top and edge of stairs; one of these people was noted to be unsteady. This person’s care plan stated they “could not understand the difference between stairs and floor”, yet no evidence or risk assessment was in place to ensure the provider had assessed the people’s individual risks when allocating their rooms.
Some people’s care plans noted they required sensor mats to be checked hourly due to a known risk of the person unplugging them. However, their daily notes did not evidence this was being done. Therefore, the provider did not demonstrate people’s care and treatment was routinely monitored to ensure outcomes were positive, and consistent in line with expectations.
We reviewed information regarding premises checks and certificates; these were completed regularly and within date. The provider had a system and process in place to review and audit the environment. However, the concerns we identified demonstrated that this audit was not entirely effective.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.
Some people’s care plans noted they had required support with hoisting.The provider was unable to demonstrate that all staff had been assessed as competent, as three of the 16 care staff had not yet been signed off as competent.This did not ensure people would be supported by skilled staff to mitigate the risk of harm whilst transferring.
At the time of our visit, only 6 out of 21 staff had completed Epilepsy training despite multiple residents having epilepsy, with some experiencing seizures within the past year. The provider did not evidence staff were adequately trained and informed about this condition prior to providing care for people. This put people at risk of being supported by unsuitable staff.
Some people required support with eating. A staff member told us, “We cover the people in rooms and [on] the floor, not quite enough staff”. Another staff member said, “We are struggling in the morning, quite busy at lunchtime. Sometimes we will struggle”. The provider’s monthly call bell audit noted when staff were engaged in personal care, there were delayed responses and call bells were taking over 4 minutes to respond to. We also observed some call bells were ringing for a long time. This did not evidence appropriate staffing levels and skill mix to make sure people received consistently safe, good quality care that met their needs.
The provider’s policy noted only designated and trained personnel may undertake the administration of any medication, and all staff that have the responsibility for administering medication must be assessed and deemed competent. However, we found staff were applying prescribed topical medicine without evidence of training or competency assessments. Therefore, the provider did not ensure people were always supported by skilled, competent and experienced staff. Consequently, the risk of harm to people was not monitored or managed. This also was not identified through the provider’s audits, and it therefore could not be assured there was effective oversight and governance of people’s risk to harm or abuse.
We received mixed views from staff in relation to staffing levels. Staff comments included “It can be a bit rushed; everything gets done but it’s just the timing”, “There are a lot of residents to be fed”. Another staff said, “We don’t have time to read care plans we just look at the lists”. This did not ensure effective communication and coordination within the team to safely deliver care, support and continuity to mitigate people’s risk of harm.
Safe recruitment practices were in place and had been mostly followed, though we did identify some gaps in employment history for some staff that had not been addressed. The provider addressed this during the assessment to ensure all gaps in employment histories were verified.
Staff told us they had an induction period where they carried out initial training and were given opportunities to shadow more experienced staff. Staff told us they completed refresher training, received supervision every 3 to 6 months, and completed a mixture of in-person and online training. The registered manager told us, “We use a dependency tool, as we are getting bigger, we will be having more staff.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed the environment was clean and shared areas were tidy, and staff were wearing aprons when necessary. The registered manager told us they completed visual checks, monthly compliance checks and ensured monthly supervision with housekeeping staff. People and relatives were positive about the cleanliness of the environment and told us their rooms were clean and tidy.
We observed staff had access to personal protective equipment (PPE) and facilities for disposal. The provider had a policy and cleaning schedule in place to ensure the risk of infection was managed.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.
We identified one person’s medicine was being crushed until the GP had signed the covert administration medicine form. The provider noted this was being done in the person’s best interest, however there was no evidence of a mental capacity assessment or a best interest meeting to support this. A healthcare professional had not authorised for the provider to administer this person’s medicine in such way. This did not ensure the provider managed and administered people’s medicine in the least restrictive way, and as a last alternative method. The provider did not ensure they sought clinical advice and guidance to crush medicine. This did not ensure the effectiveness of the medicine was maintained and the effect of the medicine was optimised.
Staff told us they received training for medicine administration, and we noted they administered some people’s medicine covertly. For example, we observed one person’s medicine was put into a yoghurt; however, the person only ate a small amount from a spoon offered by staff. Despite encouragement from staff to have more, the person refused. This person’s MAR chart, PRN protocol and care plan did not instruct staff to put the medicine in yoghurt. This did not ensure people’s medicine was administered safely, effectively and in an informed way for people to understand.
We identified some people’s ‘as needed’ medicine (PRN) was written with option to take ‘half’ or ‘one’, or to take ‘1 – 2’ tablets. People’s MAR charts showed the administered dose of medicine was inconsistent, and sometimes the lowest dose available was not administered first. The provider did not ensure staff had clear guidance to understand what dose to administer based on the person’s symptoms,
One person’s care plan stated, “is currently on PRN Lorazepam to help control [their] behaviours.” This did not ensure people’s medicine was not used as a form of chemical restraint, and as the least restrictive option to support people experiencing distress and anxiety. Furthermore, there was no information in this person’s care plan how each medicine would be administered covertly, in which appropriate form, and if this method had been approved by a healthcare professional.
For another person, their MAR chart did not specify what the safe maximum dosage was for their sedative in a 24-hour period. The instructions on the person’s MAR charts stated the medicine was prescribed to be administered ‘before care’. People’s care could be provided multiple times in a day, throughout the day. This MAR chart did not demonstrate how and when staff could safely administer this person’s medicine, and what process was in place once the dose had already been administered but the person required further personal care. This meant people were at risk of their medicine not being administered safely and effectively.
Topical MAR charts were in place for people’s prescribed cream. However, body maps were not always completed to ensure medicine was applied safely and effectively.
We found people had risk assessments for emollients in their MAR chart folders. However, these were generic, and not person centred. We found one person was prescribed ibuprofen gel, which is a flammable medicine. This medicine was not listed on the provider’s risk assessment form. Therefore, the provider did not always ensure people and staff identified and understood the risks associated with individual medicine, and the action required to minimise this risk of harm to them.
The registered manager told us they completed medication audits, and the provider also completed a monthly audit. However, the provider did not identify the issues we found during our assessment. Therefore, their audits were ineffective in their use.