30 December 2022
During an inspection looking at part of the service
Surbiton Care Home is a residential care home providing personal care to up to 26 people. The service provides support to older people and those with dementia. At the time of our inspection there were 17 people using the service.
People’s experience of using this service and what we found
Risk management was not always clearly recorded to ensure staff had guidance to mitigate the likelihood of risk occurrence. Where potential incidents had occurred, these had not always been identified, reported or investigated. Management and oversight of the service required some improvement to ensure audits were effective in driving improvements.
There were enough staff to meet people’s needs, and despite the lack of written guidance staff knew how to respond to people’s needs. People received their medicines when they needed them. Staff understood how to safeguard people from the risk of abuse.
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, relatives and staff were complimentary of the registered manager and the support and passion they brought to the role. The service worked in partnership with other agencies to meet people’s needs.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 30 January 2018).
Why we inspected
We undertook this inspection as part of a random selection of services rated Good and Outstanding.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
Enforcement and Recommendations
We have identified a breach in relation good governance at this inspection.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.