Compton Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.
At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people were not always protected from avoidable harm and systems were not consistently effective. The provider was in breach of legal regulation in relation to safe care and treatment.
 

This service scored 50 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.
The provider did not consistently demonstrate a proactive and embedded learning culture. Although leaders recognised shortfalls, they did not always record, share or embed learning into practice. This reduced the provider’s ability to prevent recurrence and effectively manage risk.
For example, staff recorded and reviewed incidents such as falls, but they did not consistently document the learning identified or the preventative actions taken. This meant the provider could not be assured that lessons learned improved outcomes or reduced the likelihood of repeated incidents.
We identified concerns regarding visitor sign-in procedures on the first day of inspection and shared these with leaders. However, when we returned for the second visit, we found the same concerns remained. Staff did not consistently follow the service’s visitor sign-in procedures, which reduced the provider’s ability to account for people in an emergency. This showed that although inspectors had identified and fed back concerns to leaders, staff did not consistently act on this feedback or embed learning into daily practice.
 

The provider did not always work well with people and external partners to establish and maintain safe systems of care, particularly when people moved between services or required coordinated input from other professionals.
We received mixed feedback from partner agencies working with the provider. While some external healthcare professionals described staff as helpful and knowledgeable, others raised concerns about the provider’s systems, pathways and management of transitions.
A partner agency told us the provider did not always follow up actions after hospital discharge or professional health care input. For example, following a review by urgent community response services, a person was prescribed antibiotics for a suspected infection and staff were advised to monitor their condition. However, staff had not identified or acted promptly on this advice until this was raised during a later support visit. The partner described the service as “not very proactive.” This increased the risk that changes in the person’s health needs were not responded to in a timely way.
Feedback from stakeholders also showed the provider did not always share information proactively. One professional told us, “It can be difficult to get clear information from the service, and they are not always proactive in sharing updates.” This increased the risk to continuity of care, particularly when people’s needs changed or when they moved between services.
 

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.
The provider did not always ensure staff understood or consistently followed safeguarding systems. This increased the risk that staff did not identify, escalate or appropriately investigate concerns, placing people at risk of harm.
Staff completed safeguarding training; however, not all staff demonstrated an understanding of safeguarding processes or applied this training in practice. Some staff explained how to recognise and report concerns, but others could not describe how to escalate issues through appropriate internal or external channels. This increased the risk that staff did not report concerns in a timely or appropriate way.
Staff raised concerns about the safeguarding culture within the service. One staff member said they felt “scared to raise concerns,” and did not feel confident that the provider would act. Another described the service as “not being a safe space.” This indicated a culture where staff did not always feel able to speak up, which further increased the risk of safeguarding concerns not being escalated.
Staff told us about serious alleged safeguarding concerns that were not shared in accordance with the provider’s safeguarding policy prior to our inspection. Although leaders acknowledged gaps in staff understanding, they had not addressed these at the time of inspection. This placed people at increased risk of abuse and neglect.
However, most people and their relatives told us they felt safe. The provider had systems in place to support the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Care records included assessments of capacity, and staff recorded appropriate authorisations and best interest decisions where required. This showed the provider followed legal requirements to support decision-making.
 

The provider did not always work well with people and others to understand and manage risks. Staff did not always provide care that was safe, supportive or responsive to people’s changing needs.
We received mixed feedback about how staff involved people and managed risks to their safety and wellbeing. For example, one partner agency raised concerns about how staff monitored and responded to changes in a person’s health. Following professional input, staff were advised to monitor a person whose confusion and behaviour had changed and take further action if their condition did not improve. However, when the partner agency visited again, staff had not recognised the ongoing risk or acted promptly on the professional advice. This increased the risk that deterioration in the person’s health was not identified or escalated in a timely way.
Records did not always fully reflect staff knowledge and practice. Staff did not consistently complete care records, including gaps in recording time spent supporting people. This meant records did not always provide a clear account of care delivered, which reduced oversight of how risks were managed and monitored over time.
However, staff managed some risks well. Staff generally understood people’s day-to-day risks and took action to reduce them. For example, staff recorded dietary requirements, choking risks and referrals where needed, and we observed staff supporting a person safely at lunchtime. External professionals also gave positive feedback where staff followed guidance to support people’s mobility and independence. A physiotherapist described one person’s mobility as a “massive improvement.”
People told us staff involved them in managing risks to their wellbeing. One person explained that staff discussed risks with them and made decisions together, particularly in relation to mobility and safety.
 

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.
The provider had systems in place to monitor the safety of the environment and equipment; however, these were not always effective in practice. Oversight arrangements lacked clear structure and defined accountability, which meant staff did not consistently identify, monitor or manage environmental risks.
There was limited clarity regarding roles and responsibilities for maintaining and checking equipment. Leaders could not clearly explain who held accountability for ensuring equipment was safe and appropriately maintained. One staff member told us that issues were reported but not always resolved promptly. This lack of ownership increased the risk that staff missed or delayed essential safety checks.
We found the COSHH cupboard code was visible, which created a risk of unauthorised access to hazardous substances. Staff addressed this immediately when we raised it.
Fire safety systems were not always effective. Staff had not updated Personal Emergency Evacuation Plans (PEEPs) for 2 people to reflect their current needs, which could impact safe evacuation. A recent fire drill took approximately one hour to complete. The registered manager acknowledged this was too long; however, leaders had not recorded actions to address the concerns identified or improve evacuation times. This increased the risk that people would not be evacuated safely or promptly in an emergency.
We identified concerns with maintenance record-keeping. Records contained discrepancies across multiple entries and dates, with indications that staff completed some records retrospectively. This meant records were not always reliable and reduced assurance that leaders maintained effective oversight of the premises and equipment.
 

The provider did not always ensure staff were suitably skilled, supported or effectively supervised. Leaders did not consistently embed training into practice, and oversight of recruitment and workforce compliance was not always robust. This increased the risk that staff did not always deliver safe care consistently.
Staff completed mandatory training; however, leaders did not always ensure staff understood and applied this in practice. For example, not all staff demonstrated an understanding of key areas such as safeguarding procedures. One staff member told us they were unsure who to report concerns to outside the home, which raised concerns about their ability to respond appropriately to safeguarding risks.
Leaders did not always maintain effective oversight of staffing compliance and workforce management. For example, leaders did not identify a breach of visa working hours through internal checks. A staff member who worked in the service but did not appear on the rota. This raised concerns about oversight, accountability and safe staff deployment. These issues reduced assurance that leaders managed staffing systems effectively.
However, people and relatives generally told us there were enough staff to meet their needs and that staff were competent in their roles. During the inspection, we observed sufficient staff on duty to meet people’s needs, and the provider’s dependency tool supported this.
Staff told us they completed an induction and the recruitment process and described receiving support when they first started. This showed the provider had systems in place, but leaders did not always use them effectively to ensure consistent safe practice.
 

The provider did not always assess or manage the risk of infection. They did not consistently identify or control the risk of infection spreading.
Staff did not consistently follow infection prevention and control (IPC) practices. We found a communal toilet was dirty and unhygienic on the first day of inspection. When we returned, we found the same toilet remained unclean, including contaminated waste on the floor. This showed staff did not consistently maintain hygiene standards or act on identified concerns. We also observed poor personal hygiene practices, including unclean nails for people using the service. A senior staff member did not follow IPC and uniform policies, as they wore long acrylic nails. This increased the risk of infection, cross-contamination and the spread of illness.
Partner agencies also raised concerns about how staff managed a recent diarrhoea and vomiting outbreak. This reduced assurance that staff consistently identified, managed and communicated infection risks.
Leaders completed IPC audits; however, these did not demonstrate effective learning or sustained improvement. This meant leaders did not always maintain effective oversight of infection control practices.
However, some areas reflected good practice. The kitchen was clean and well organised, and staff followed appropriate food hygiene standards. Staff had access to personal protective equipment (PPE) and hand hygiene facilities. Domestic staff told us “I have all of the equipment I need.” Where leaders identified issues, such as flooring concerns, they took action by increasing cleaning schedules and replacing flooring. This showed the provider had systems in place, but they were not consistently followed.
 

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.
Staff did not always manage medicines safely. We identified that some PRN protocols did not provide clear guidance for staff about the symptoms or behaviours a person may display that would indicate when a PRN medicine should be administered. PRN medicines are prescribed to be taken as needed or when required, rather than on a strict, regular schedule for example for pain relief. The lack of clear guidance meant staff may not administer these medicines consistently or in line with people’s needs.
Feedback from a partner agency also described an occasion where staff had not identified a change to a person’s medicine following hospital discharge until this was raised during a support visit. This showed staff did not always have effective systems to check and act on updated medicines information. This increased the risk that people did not receive medicines in a timely manner following health care advice.
We observed that staff did not consistently explain medicines to people during administration or follow hand hygiene practices. This increased the risk that people were not fully informed about their medicines and increased the risk of cross-contamination.
We observed a medicines administration error during a medicines round. Although staff identified and corrected the error at the time, this demonstrated a risk within medicines administration practices and reduced assurance that staff always followed safe procedures.
However, some aspects of medicines management were effective. The medicines room was well equipped, and staff completed and maintained temperature checks for both the room and fridge. Staff respected people’s choices when they refused medicines and followed the provider’s policy by recording and escalating refusals appropriately.