Surrey Heights

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question ‘Good’. At this assessment the rating has changed to ‘Requires Improvement’. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The service was in breach of legal regulation in relation to governance and oversight at the service.
 

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.
The service provided evidence of staff meetings. However, we received mixed feedback from staff about meetings. Staff told us the meetings took place, and they were informative. Staff said they used these meetings to discuss any new residents joining the service. Some staff were positive about their communication and ability to speak directly with the registered manager, adding the “Manager is helpful, she will solve our problems”. Other staff told us, “We are free to talk to team leaders and manager, but they don’t always listen…we talk at staff meetings but there isn’t much time to talk more about issues.”
Staff did not always feel able to talk to their immediate line managers. Some staff told us “We raise the issues with team leaders, but I feel there is a big communication gap…most times I will raise myself with the manager”. Staff also told us “People have quite high needs; mental health is a bit of an issue, [leaders] make the decision who is admitted.” This did not ensure staff were always involved in the provider’s vision or strategic goals or understood their role in achieving them.
The registered manager told us they, “Think there are strategic goals for the service; [to] make sure everyone lives their best life independently as possible, encourage residents to live a more proactive life as the service grows”. The service was undergoing an extensive refurbishment. The registered manager told us staff were excited about the greater opportunities the new facilities would bring.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.
Staff told us “We have 4 team leaders, and each person is different, some are better than others”, “Everyone here is very relaxed, and all have time for you”.
We observed the registered manager supported people when eating. We found the management team approachable, compassionate and open throughout our assessment. However, the registered manager was not always aware of some issues we identified during our assessment. Staff expressed concern about supporting some people with greater mental health needs, especially during incidents of distress.
We observed an altercation between residents; staff told us they were concerned and “everyone is just scared”. We shared this information with the registered manager. They were not aware of all the incidents this resident had been involved in.

People did not always feel they could speak up and that their voice would be heard.
We received mixed feedback from staff. A staff member told us, “Communication between staff is ok but with managers, staff don’t speak up. “There isn’t an immediate response and in that time something else may happen.” Another staff member said, “The manager would always say come to my office, but the team leader does not want us to come to the office.” The provider did not ensure leaders actively promoted and empowered staff to drive improvement. Leaders did not always encourage staff to raise concerns and promote the value of doing so.
Staff were aware of raising and reporting concerns to their team leaders and manager, however they were not always aware of the term ‘whistleblowing’ and of any external agencies which could also be contacted to raise concerns.
The registered manager told us they encouraged a culture of openness “by being open with the staff, greeting everyone, [talking] to them all everyday”. There were systems to enable people to speak up. Resident meetings were held, and there were systems for capturing staff feedback such as staff meetings.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.
Different cultures and religions were represented within the workforce. Staff were treated and supported as individuals. Staff told us “They are very supportive to us; we have to balance work and family. It is a nice place to work”. Staff told us they completed equality and diversity training, as well as celebrating cultural events with staff and people using the service.
The registered manager told us action they had taken to improve the culture of the organisation in the context of equality, diversity and inclusion. The registered manager gave us examples where they had taken action to improve where there were any disparities in the experience of staff and to prevent and address bullying. The registered manager told us they supported requests for flexible working, and celebrated cultural events to ensure diverse staff culture was supported and celebrated.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
The registered manager did not ensure effective oversight of training to ensure people were always supported by competent and trained staff. We also noted one staff member responsible for administering medicine was overdue their medicine competency.
Staff did not always follow the process to report accidents and incidents. Consequently, this did not ensure the registered manager had effective oversight and governance of risk to people in the service. For example, we found incidents involving altercations between residents were recorded on Antecedent, Behaviour and Consequence (ABC) forms. The registered manager told us if these had been recorded on incident forms, they would have been aware. As they were recorded on ABC forms, they did not automatically come through to the manager. We shared our findings with the registered manager; they stated staff were aware incident forms should be completed when there was an incident between residents.
People’s care records were contradictory and contained inaccurate information. This did not ensure effective governance of people’s care and records. This also did not ensure staff had clear information to follow which was reflective of how to best support people, and most reflective of their current needs. We found two people’s care plans stated they did not have allergies, yet in other sections of their care plan allergies to medicines were noted. This did not ensure people would always be protected from the risk of avoidable harm or abuse, and that medicine would always be administered safely in line with this information. The provider did not evidence they managed and monitored people’s risks to ensure the examples we identified during our assessment were identified in their own audit systems and processes.
Staff did not ensure healthcare professionals were contacted in a timely manner regarding people’s medicine.
We identified one person’s care plan included details of another person’s care needs. The provider did not demonstrate governance and management of people’s records to ensure accuracy and maintain clarity. The provider’s audit process failed to identify and address these examples we found during our inspection. The registered manager told us the service used handovers and observations to identify any risks, and to ensure the environment was safe, maintained standard of compliance with health and safety.
The provider completed quality assurance audits each month, including people’s care plans and medicine. The audit processes failed to identify and action the concerns found during this assessment.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.
The registered manager told us how they worked in partnership with and involved external professionals such as the occupational therapists, district nurses, SaLT and GP when needed. The associated GP would complete weekly visits to the service and the weekly clinical meeting updates were recorded in the provider’s folder.
The registered manager also told us about how they supported people to access external services in the community, including visits to the local garden centre and the provider’s nearby nursing home according to their preference. The service also worked in partnership with initiatives including ‘Adopt a Grandparent’, and forming relationships with local schools, colleges and foodbanks. We have been able to gather limited feedback from partners despite our requests.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.
We review staff handover notes and found incidents were mentioned. However, it was unclear from the handover notes how the provider ensured all staff reviewed and understood the information. We saw some examples of lessons learned following incidents, and we saw how the registered manager analysed areas such as falls to look for patterns and trends. However, we identified examples of risk during our assessment which were not identified or actioned by the provider. Staff told us they found their meetings helpful, and “we can give suggestions but whether it is taken up I don’t know. Maybe on a few occasions."
The provider was working with an agency in relation to a new system to prevent falls. However, there were still elements of practice which needed improvement as highlighted throughout the report.