Surrey Hills

Updated 15 November 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection site visit was carried out by 2 inspectors and a specialist nurse advisor. It was supported remotely by an Expert by Experience who is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Surrey Hills is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Surrey Hills is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service and 6 relatives of the people about their experience of the support and care provided. We observed the care and support people received in the communal areas of the home. We spoke with 10 members of staff including the registered manager, the regional manager, nurses, care, activity and housekeeping staff and the chef.

We reviewed a range of records. This included 5 people’s care plans and elements of specific care documentation for other people, as well as multiple medicines records. We looked at recruitment checks and training records for 3 staff members. A variety of records relating to the management of the service, including quality assurance checks, policies and procedures were also reviewed. We received feedback from 2 healthcare professional working with the home.

Updated 15 November 2022

About the service

Surrey Hills is a nursing care home providing accommodation, nursing and personal care to up to 45 people. The home provides care and support to older and younger adults, people with physical support needs, multiple health related care needs and people with dementia. At the time of our inspection there were 34 people using the service.

People’s experience of using this service and what we found

People received support which was overall personalised. However, staff did not always address people’s specific dementia support needs around their distress in a consistent way. The home provided support to many people with advanced dementia, so staff (especially new) required additional guidance and training.

The home environment and specific adaptations around dementia and the availability of meaningful engagement required improvement. We shared our feedback with the management who took immediate action to provide additional support and resources to staff to support people with complex dementia needs better.

People were supported safely with medicines. People’s individual risks and health needs were addressed in their care plans. There were enough staff to provide care to people in a timely way. New staff were recruited safely. People were supported to access healthcare as needed. Staff followed good infection prevention and control practice.

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’s care plans were personalised. People received support to eat and drink well. People had opportunities to attend activities and events in the service and to host visitors. Staff respected people’s choices and independence.

People and their relatives were complimentary about staff and the management. A relative told us, “[Staff] are lovely and kind.” Staff felt supported and listened to and were very positive about their manager. One staff member told us, “[The registered manager] is a nice man with a big heart, very human, he talks a lot to the residents.”

The provider had good governance systems in place which enabled the management team to monitor the key areas of quality and safety of the service. The management team had identified actions and lessons learnt which were then implemented to improve the care provided to people. For example, clinical meetings were held to review and adjust individual people’s care. Staff were also supported to improve recording of the day-to-day care they provided to people.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 11 August 2021 and this is the first inspection with ratings.

The last rating for the service under the previous provider was good, published on 20 December 2019. The service was inspected but not rated and assured around infection prevention and control practice, published on 3 March 2022.

Why we inspected

This inspection was prompted by the length of time since the changes in registration of this service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.