CQC report explained · a residential care home
What the CQC found at Surbiton Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2023
Surbiton Care Home was rated Requires Improvement; inspectors found gaps in risk records, incident investigations and management checks.
The inspection was unannounced and took place on 30 December 2022. One inspector spoke with people living at the home, a relative, staff and managers. They reviewed care records, medicines records, recruitment files and management documents.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found enough staff, safe recruitment, generally safe medicines administration and good infection control. However, some risks were not recorded clearly, two incidents had not been properly reported or investigated, and management checks had not found these problems.
The rating had fallen from Good at the previous inspection, published in January 2018. The provider took some immediate action during or after the inspection and sent an action plan. CQC said it would monitor progress and inspect again.
Staffing
Inspectors found enough staff to meet people's needs. Staff had time to interact with people and were not seen to be rushed.
“Staffing levels were sufficient in meeting the needs of people living at the service.” from the report
People felt safe
People told inspectors they felt safe. Staff understood how to raise safeguarding concerns and escalate them when needed.
“People were safeguarded from the potential risk of abuse and told us they felt safe living at the home.” from the report
Legal safeguards
The home was working within the principles of the Mental Capacity Act. Where needed, legal authorisations were in place.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including the use of protective equipment and visitor safety.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Missing risk assessments
seriousSome people's risk assessment sections were blank, and paper assessments were not available. This meant staff did not always have clear written guidance to reduce risks.
“Potential risks to people were not always recorded and risk assessment and management plans were not in place.” from the report
Incidents were not investigated
seriousTwo incidents found in daily notes had not been reported, recorded or investigated. Inspectors could not be assured that lessons had been learned.
“We identified two incidents within people' daily notes that had not been reported, recorded or investigated.” from the report
Medicines records
needs fixingPeople received their medicines when needed, but staff did not always record why they gave medicines prescribed as required.
“Staff were not always recording the reason for PRN ['as required'] medicines administration.” from the report
Weak management checks
seriousAudits and other checks had not identified important problems with risk records, incidents and medicines records. This was a breach of the good governance regulation.
“The failure to maintain sufficient oversight and governance of the service was a breach of Regulation 17 of the Health and Social care Act 2008 (Regulated Activities) 2014.” from the report
- 01Have all risk assessments and risk management plans now been completed, including plans for anxiety or distress?
- 02What happened in the two incidents that were not reported or investigated, and what changes were made afterwards?
- 03How do you now check that staff record the reason whenever they give an as-required medicine?
- 04What does the new electronic case management system show about current risks and completed reviews?
- 05When will you review the action plan and share evidence that the Regulation 17 breach has been addressed?
This inspection focused on Safe and Well-led, including infection prevention and control; the other three key questions were not rated and the previous overall rating was from 2018. This explanation was written from the published report of 28 January 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2022
Inspected but not rated; inspectors found strong infection prevention and control arrangements.
This was an announced, targeted inspection on 24 January 2022. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors found thorough entry screening, regular testing, enough protective equipment and updated infection control training. They also found the home clean and hygienic, with plans for managing infections and supporting people to isolate safely.
The home was inspected but not rated overall. The Safe question was also inspected but not rated. This report does not assess the wider quality of care or give ratings for the other questions.
Entry screening
The home used testing, temperature checks, screening forms and protective equipment when people entered.
“Thorough screening procedures were utilised upon entry into the home.” from the report
Protective equipment
Inspectors found plentiful protective equipment and plans to keep supplies available.
“There were sufficient levels of PPE available across the home for staff to use throughout their shift.” from the report
Keeping families connected
People could see loved ones through screened visits or video calls where needed.
“People were supported to see their loved ones through the use of screened visits or video calls where necessary.” from the report
Clean environment
The home was clean and had regular cleaning schedules to reduce the spread of infection.
“The home was clean and hygienic throughout with regular cleaning schedules in place to stop the spread of infection.” from the report
Inspectors raised no specific concerns in this report.
- 01How are people and staff tested now, and how are positive test results managed?
- 02How do you make sure there is always enough protective equipment available?
- 03What are the current arrangements for visits from relatives?
- 04How do you support a person who needs to isolate after testing positive?
- 05How often is infection prevention and control training updated for staff?
This was a targeted inspection of infection prevention and control only; it was not a full inspection and the service was inspected but not rated. This explanation was written from the published report of 10 February 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Surbiton Care Home
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- January 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- January 2018GoodSafe: GoodWell-led: Good
- January 2017
Registered with the Care Quality Commission on 26 January 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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