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 responsibil

The inspection of Surrey Heights took place on 27 April 2017 and was unannounced. This inspection was to follow up on actions we had asked the provider to take to improve the service people received.

Surrey Heights is registered to provide accommodation with nursing care for up to 39 people. At the time of our visit, there were 26 older people living at the home. The majority of the people who lived at the home were living with dementia and a mental health diagnosis. The accommodation is provided over three floors that are accessible by stairs and a lift. The service is a detached house with communal lounges, dining room, kitchen and bathroom facilities.

There was a registered manager in post however they were not 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. On the day of the inspection we were supported by the deputy manager. Since the inspection changes to the management arrangements have taken place and a new manager is in post who will apply to register with the commission.

At our previous inspection on 18 May 2016 we found a breach in relation to ineffective recruitment systems. We also made two recommendations to the provider in regard to infection control, to improve care plans and improvements around the supervision of staff. The provider sent us an action plan and provided timescales by which time the regulations would be met. They stated that the actions would be completed by 1 September 2016.

During this inspection we found that although some improvements had been made in regard to our recommendations and breach of regulation we found new concerns that put people at risk of harm.

People were at risk because there were inadequate systems and arrangements to protect people from the spread of infection. Appropriate standards of cleanliness were not being maintained. Infection control policies and procedures were in place; however staff had not followed these. We raised concerns about the conditions of mattresses, furniture, commodes, and bedding in the home.

There were insufficient numbers of staff deployed to meet people’s needs. This had an impact on the care and support provided and the cleanliness of the home.

People were not always safe because up to date risk assessments were not in place to identify, assess and manage risk safely and to minimise the risk of harm to people.

Staff did not have a clear understanding of their responsibilities regarding the Mental Capacity Act or Deprivation of Liberty Safeguards. Where people lacked capacity they were not fully protected and best practices were not being followed. MCA assessments were not being completed specific to particular decisions.

There were inconsistencies in how staff used their training and put this into practice which put people at risk. We made a recommendation that the registered provider follow their policy in relation to supervision to ensure staff received appropriate support and supervision for their role.

The home could be improved because it was not easy for people living with dementia or who had impaired sight to find their rooms or their way around the service as all areas looked the same. We made a recommendation that the provider researches and implements relevant guidance on how to make environments used by people who live with dementia more ‘dementia friendly’.

People were not always treated with dignity and respect. There was a strong smell of urine in people’s rooms and in the corridor outside rooms that people had to endure. Staff were not always listening to what people wanted.

Some peoples’ rooms were bare and lacked personalisation. Other rooms did have people’s own furniture and pe

The inspection of Surrey Heights took place on 18 May 2016 and was unannounced. This inspection was to follow up on actions we had asked the provider to take to improve the service people received.

Surrey Heights is a care home which provides accommodation and personal care for up to 39 people. At the time of our visit there were 24 people living at the home most of who are living with dementia. The accommodation is provided over two floors that were accessible by stairs and a lift.

At the time of our visit there was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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 not always protected from being cared for by unsuitable staff because although recruitment processes in place, they were not always followed.

Although quality assurance systems were in place and had improved. We have made a recommendation with the intention that quality assurance systems continue to improve to identify and rectify record keeping and staff practices.

Although the home was clean, people were not always safe because the processes in place to prevent and control infection were not always followed by staff. We have made a recommendation that the provider ensures that staff follow the current guidelines and policies in regard to infection control.

People and relatives told us they were safe at Surrey Heights. Staff had a good understanding about the signs of abuse and were aware of what to do if they suspected abuse was taking place. There were systems and processes in place to protect people from harm.

There were sufficient numbers of staff deployed who had the necessary skills and knowledge to meet people’s needs.

Medicines were managed, stored and disposed of safely. Any changes to people’s medicines were prescribed by the person’s GP and administered appropriately.

Fire safety arrangements and risk assessments for the environment were in place to help keep people safe. The service had a business contingency plan that identified how the home would function in the event of an emergency such as fire, adverse weather conditions, flooding or power cuts.

Staff were up to date with current guidance to support people to make decisions. Staff had a clear understanding of Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) as well as their responsibilities in respect of this.

The registered manager ensured staff had the skills and experience which were necessary to carry out their role. Staff had received appropriate support that promoted their development. The staff team were knowledgeable about people’s care needs. People told us they felt supported and staff knew what they were doing.

People had enough to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. People were supported to have access to healthcare services and were involved in the regular monitoring of their health. The provider worked effectively with healthcare professionals and was pro-active in referring people for assessment or treatment.

Staff treated people with compassion, kindness, dignity and respect. People’s preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people’s wishes. People’s privacy and dignity were respected and promoted when personal care was undertaken.

People’s needs were assessed when they entered the home and on a continuous basis to reflect changes in their needs. Staff understood the importance of promoting independence and choice. People were able to personalise their room with their own furniture and personal items so that they were surrounded by things that were familiar to t

Surrey Heights is a care home that provides accommodation and support for up to 39 people most of whom are living with dementia. There were 26 people living in the home on the day of our visit. Accommodation is arranged over two floors and there is a lift to access the first floor.

The home did not have a registered manager in post on the day of our inspection. A registered manager is a person who has been registered with the Care Quality Commission 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 and associated Regulations about how the service is run. There was manager in the home who was not registered with CQC.

Some people told us they were treated well by staff who were kind and caring. However some people’s dignity was not always maintained. We noted when people were sitting in the lounge their walking frames were stored in a room next door to discourage them from getting up unaided and to have the freedom to walk around the home. This showed us staff were not respecting autonomy and promoting their independence. We saw staff knocked on people’s doors before they entered.

Not all staff had undertaken training regarding safeguarding adults and were not aware of what procedures to follow if they suspected abuse was taking place. There was a copy of Surrey’s multi-agency safeguarding procedures available in the home for information.

Risk assessments were in place for all identified risks for example choking. However staff were not always following correct procedures to keep people safe. For example not completing records as required. We looked at the medicine policy and found medicine administration was not managed safely.

Care plans were not always reviewed and kept up to date. For example one person’s diabetic care plan was not maintained and their blood sugar levels were not recorded daily as agreed.

Generally people’s health care needs were being met. People were registered with a local GP who visited the home weekly. Visits from other health care professionals also took place.

People had sufficient food and drink to maintain a healthy lifestyle, and people were complimentary about the food.

Staff recruitment procedures were safe and the employment files contained all the relevant checks to help ensure only the appropriate people were employed to work in the home.

People were engaged in activities for an hour during the morning. No activities were taking place during the afternoon and we saw people wandered about or sleeping in their chairs unoccupied or without support from staff.

Systems were in place to monitor the service being provided. Health and safety audits were undertaken and customer feedback surveys were undertaken.

People had been provided with a complaints procedure. We looked at the complaints record and noted no complaints were recorded. We saw several thank you letters and cards from relatives expressing their appreciation and gratitude for the care provided their family member.

There were aspects of the home that needed to be managed better. For example the standard of cleanliness required improvement and the standard of record keeping needed to be maintained to an acceptable standard. For example care plans were not always reviewed, cleaning schedules were not kept up to date and turning charts were not maintained appropriately placing someone at risk of developing pressure ulcers.

During the inspection we found several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

When we previously inspected this service on 8 October 2013 we identified areas of non-compliance. The provider sent us an action plan that detailed the actions they planned to take to ensure that they achieved compliance. The purpose of this follow-up inspection was to review the actions that the provider had taken.

We spoke with three people and one person’s relative. Many people had a diagnosis of dementia and some were not able to communicate with us in a meaningful way. Therefore we used our Short Observational Framework for Inspection (SOFI) to enable us to observe people's experiences of the care provided. We spoke with two visiting professionals about the service people received.

We found that staff were caring and responsive to people’s needs. One person told us that it was “Very nice” and another person’s relative told us “There are some wonderful staff.” Health professionals told us that they had no concerns and that the service had improved.

We found that adequate information had been provided to people.

Staff had improved the quality of their interactions with people. Action had been taken in relation to people’s sensory mats.

The home was clean and infection control guidance had been followed.

There was evidence of the required pre-employment checks for agency staff.

Staff had received regular supervision that had been documented.

The provider had monitored the quality of the service provided.

Records were kept securely.

On the day of the inspection there were 22 people who used the service. We spoke with two people and one person’s relative about their experience of the service. People were satisfied with the service they received. One person commented ‘Service is fine’ another told us ‘I get the service I expected.’

We found that a number of people had dementia and that insufficient information had been provided for their needs.

People had care plans and risk assessments in place. However people’s care had not always been delivered in a way that promoted their welfare and safety.

There were processes in place to safeguard people.

Infection control guidance had not always been followed.

The provider was unable to provide evidence that the required pre-employment checks had been completed in relation to all agency staff.

Staff had not all received regular supervision, in particular agency staff.

There were systems in place to identify and assess risks to people, however, these were not fully effective.

People’s personal records had not been stored securely.

In this report the name of a registered manager appears who was not in post and not

managing the regulatory activities at this location at the time of the inspection. Their

name appears because they were still a Registered Manager on our register at the time.

We were told that the service was currently supporting 19 people.

We used a number of different methods to help us understand the experiences of people using the service. Some people using the service were able to tell us about their experiences and their comments have been included within the report.

Other people using the service had complex needs or experienced cognitive impairment due to dementia which meant they were not able to tell us their experiences.

In order to help us to understand the experiences of people have we used an expert by experience who observed and spoke with people using the service to help us to get a clearer picture of what it is like to live in or use the service.

We also gathered evidence of the service provider's performance through speaking with a healthcare professional during our visit and receiving feedback from people’s relatives, and sampling records and documents before and after our visit.

We were told that the service was currently supporting 21 people.

The majority of people that use the service at Surrey Heights have dementia and therefore not everyone was able to tell us about their experiences.

To help us to understand the experiences people have we used an expert by experience and also used our SOFI (Short Observational Framework for Inspection) tool.

The expert by experience observed and spoke with people using the service to help us to get a clearer picture of what it is like to live in or use the service.

The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences.

Some people using the service were able to tell us about their experiences and their comments have been included within the report.

The atmosphere in the service was welcoming and calm.