Archived: Surrey Heights

Updated 13 January 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control (IPC) practice was safe and the service was compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place.

This inspection took place on 16 December 2020 and was unannounced.

Updated 13 January 2021

Surrey Heights is registered to provide residential accommodation and personal care for up to 39 people. At the time of our visit, there were 23 people living at the home. Most of the people who lived at the home were living with dementia and some were also physically frail.

This inspection took place on 5 July 2018 and was unannounced.

At the last inspection, on 27 April 2017, we found there were six breaches of the regulations. These were in relation to the safe care and treatment of some people, insufficient staffing levels, consent to care, premises and equipment, dignity and respect and good governance. We asked the registered provider to complete an action plan showing what they would do to address all the issues we found and to meet the regulations.

The registered provider acted to improve the living conditions in the premises and upgraded all the beds and bedrooms for people. They temporarily stopped admissions to reassess levels of dependency and the staffing they required to be able to safely meet people’s needs. A staff recruitment programme and new induction was developed. The approach used for mental capacity assessments and consent was reviewed. Significant changes were made to the way the service was managed, governed and audited.

At this inspection we found that the improvements we had been told about had developed and were being sustained. We could see the impact these changes had on the quality of people’s care and on their lives.

There was a registered manager present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were being cared for by sufficient numbers of staff who were working well together to maximise their time and roles. Staff recruitment was safely managed and the registered manager continued to reduce their reliance on agency staffing. There was a commitment by staff to enabling people to be safe and to improve their well-being and happiness.

People were protected from abuse and there were systems and processes in place to deal with safeguarding incidents. Staff were aware of their role and felt confident to speak up about any concerns.

People’s needs and risks were routinely and well assessed and monitored. Changes were made to care plans and staff were aware of the risks and took appropriate actions to keep people safe. The risk of falls was being managed well and staff were involved in identifying patterns and solutions for some individuals.

There had been a big improvement in the cleanliness and condition of the home. A re-decoration and deep cleansing programme had been undertaken and the standards within the premises were being maintained.

Medicines management and administration was safe. The service had a robust audit process and any errors were picked up very quickly. There was an emphasis on staff learning from these and training was put in place where needed.

Staff were vigilant in addressing people’s health and care needs. They had received training in caring for people living with dementia and this was evident in the way they supported people throughout the day. Staff received a good induction when they started. There was a clear staff structure in place and the care staff were supported and formally supervised. People were supported to stay healthy and to receive medical treatment when they needed it.

People had access to food, snacks and choice of drinks during the day. The menus and choice at meals had improved and the food was praised. The way meals were served and the pleasant environment meant people were enjoying their food and their nutritional health benefitted.

The registered manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Capacity assessments were evident and people’s best interests had been considered when decisions that affected them were made. Applications for DoLS authorisations had been submitted where restrictions were imposed upon people to keep them safe.

People were cared for by kind and attentive staff who clearly had a positive relationship with people. Staff created a calm and relaxed atmosphere in the home and we saw that they spoke with people in a respectful yet warm and friendly manner. People’s independence and dignity was being valued and protected. Relatives were welcomed into the home.

We noted there had been a big improvement in the care plans, that reflected people’s assessed needs, personalities, interests and preferences in appropriate language. There was information accessible to staff to that they could know people and provide a person-centred approach in their care. Work was underway to develop a ‘life story book’ for each person, reflecting who they were, and the important people and events in their lives.

Activities were happening during the day and were varied and appropriate. People made a choice about what to take part in. In the communal areas we saw staff talking with people individually and that people were engaged and content.

The complaints procedure was clearly displayed around the home. There was a clear process for managing complaints and we saw that these were responded to in a clear and timely way, with a record of actions taken.

People’s wishes for end of life were recorded. The service had worked with local doctors to enable people to record their preferred place of care in the event of illness.

The registered manager provided strong leadership to set new standards of care and to look for areas where they can continuously improve. There was a positive culture. Staff were proud to work at the home and contribute their own ideas to how people’s lives can be improved.

There was a monthly clinical governance and quality assurance system in place to ensure that all key areas of the service were monitored. There was recorded evidence that this was effective and management oversight was strong. The legal requirement for statutory notifications to the CQC were understood and met.

People, relatives and professionals gave us very positive feedback about the visible improvements and changes that have been made at the home and in the way the care is provided. The management has been open to new ideas and sought out the resources, best practice and evidence to develop the service. We saw there was an ambition to develop further and ensure that quality care and strong values were embedded into the culture of the service.