Surbiton Care Home

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. At our last inspection we found no evidence that people had been harmed however, governance systems in place were ineffective in identifying areas for improvement and providing oversight. This was a breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found enough improvement had been made and the provider was no longer in breach of regulation 17.

This service scored 75 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Cultural differences were respected and celebrated. People were involved in planning their care because the service had recognized what was important to them.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. People told us the registered manager was approachable, commenting, “[Name of the registered manager] is the manager, she is excellent. Really good at her job. [Name of the registered manager] is easy to speak with. I can’t speak more highly of her.” Staff felt well supported in their job. They said, “I have all the support I need from the manager, I don’t have any problem here. The management is supportive. When I want to ask something, the manager never tells me she is busy.”

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard. Staff knew the actions they had to take if their concerns were not adhered to appropriately by the provider. Comments included, “[Name of the registered manager] is always very responsive to problems. But if she is not doing anything, I would call the regional manager and then the Local Authority and Care Quality Commission.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for staff who worked for them. Staff’s well-being was promoted and included support to access counseling and medical care.

Since our last assessment, improvements had been made to ensure effective monitoring of care delivery. The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. We saw regular audits being carried out in relation to people's care records, staff files, health and safety, infection control and medicines management. Actions identified were completed as necessary and in good time.

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. People were involved in making decisions about their care and support needs. Staff asked people’s permission before providing care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. There were improvements made at the service since our last inspection making sure people were provided with safe and effective care. Provider's oversight was used to monitor and embed good practice at the home and included regular checks of care and quality assurance documentation.