Compton Manor

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 leadership, management and governance assured high-quality, person-centred care and supported learning. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant leadership and governance systems were not consistently effective in assuring high-quality care or driving improvement. The provider was in breach of legal regulation in relation to governance.
While we found significant shortfalls in senior leadership, governance and culture, we also found the registered manager maintained day-to-day oversight of the service and staff described positive support at service level. People and relatives generally gave positive feedback about staff, and we observed kind, respectful care. This meant the impact of the governance shortfalls had not resulted in consistently poor experiences for people, although significant improvement was required.
 

This service scored 36 (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 have a clear or consistently shared vision, strategy and culture that was based on transparency, inclusion and engagement.
Senior leadership did not always communicate openly with the registered manager. This limited shared understanding of risks, priorities and expectations and contributed to inconsistent leadership across the service.
Staff raised concerns about fairness and inclusion within the team. One staff member told us, “Some staff are treated better than others.” This showed the culture was not consistently inclusive for all staff.
Leaders did not demonstrate how they embedded values or ensured all staff understood and worked in line with a shared vision.
However, the registered manager promoted a person-centred approach at service level. Staff described positive working relationships locally and felt supported in their day-to-day roles.
 

Leaders did not consistently demonstrate compassionate, inclusive or effective leadership. Senior leadership did not promote a culture of openness, respect or psychological safety, which negatively impacted staff wellbeing and the wider service culture.
Staff described senior leadership behaviours that were not respectful or supportive. One staff member told us, “They do not speak nicely to me, I feel ignored,” and another said, “They speak to me in a commanding way.” Staff also described senior leadership as unpredictable. One staff member told us, “I feel worried to come to work as I don’t know how senior leadership is going to be with me.” Another described feeling “bullied and intimidated.” Although some staff gave positive feedback about senior leadership, with one staff member stating, “I am happy working here and feel supported,” this was not consistent with the wider feedback we received. This showed some leaders did not consistently create a safe or supportive working environment.
Senior Leadership did not demonstrate how they had recognised or addressed the impact of these behaviours on staff wellbeing or service culture. This reduced staff confidence and contributed to a culture where staff felt unsupported.
However, the registered manager was visible, approachable and supportive at service level. Staff described positive working relationships locally and felt supported in their day-to-day roles.
When concerns were fed back, senior leadership acknowledged issues and said they had started reviewing governance arrangements, particularly staff wellbeing. However, these actions were not yet embedded or improving staff experience.
 

Staff did not feel able to speak up and did not feel confident their concerns would be acted on. Senior Leadership did not create a culture where staff felt safe to raise concerns without fear
Staff described fear of negative consequences. One staff member told us, “most of my colleagues are in fear of saying anything negative about the home.” Staff lacked confidence that raising concerns would lead to change. One staff member told us, “I feel that if I speak up it will lead to negative consequences.” Staff also told us that when concerns were raised with the Registered Manager, senior leadership then isolated them and treated them differently. This showed staff did not feel safe to speak openly.
Leaders did not demonstrate how they encouraged speaking up or responded effectively to concerns raised. This reduced opportunities to identify risks, learn from feedback and improve the service.
Although the provider had a whistleblowing policy, speaking up and freedom to speak up policy and information displayed, staff did not feel assured their voices would be heard or action taken. Subsequently, this indicates that the provider is not adhering to their own policy.
 

The provider did not always promote an inclusive and fair culture or ensure equality and equity for all staff.
Staff described inconsistent experiences within the team, including concerns about fairness and favouritism. This reduced confidence that all staff were treated equitably.
Staff also described communication practices that reduced inclusion, one staff member told us, “a lot of staff speak in a different language, and I don’t know what they are saying and that makes me feel uncomfortable.” this affected their sense of belonging.
Senior Leaders did not demonstrate how they reviewed or addressed these concerns or promoted equality, diversity and inclusion across the workforce. Systems such as supervision were in place but did not consistently identify or resolve issues.
However, the workforce was diverse, and some staff described positive working relationships at service level. Staff found the registered manager approachable and felt able to raise day-to-day concerns.
 

The provider did not have effective governance systems to identify, assess and mitigate risks or drive improvement. Leaders did not consistently act on information about risk, performance and outcomes, which placed people and staff at potential risk.
Leaders did not implement robust systems to monitor safety and performance. For example, the provider did not have a reliable system to monitor call bell response times. Informal checks did not provide consistent oversight, which reduced assurance that people received timely support.
Leaders did not consistently escalate, monitor or act on staff concerns. Feedback about culture, communication and wellbeing was not effectively captured or addressed through governance systems. This showed leaders did not use available information to drive improvement.
Governance failures were reflected across the service, systems had not consistently identified or addressed risks relating to professional advice, medicines changes and transitions in care. We identified gaps in records, inconsistent risk monitoring and failure to embed learning. Leaders also did not maintain clear communication across the leadership team, which reduced shared understanding of risks and priorities.
Although the registered manager maintained oversight at service level, governance systems were not effective at organisational level.
When we feedback our concerns, senior leaders acknowledged the need to strengthen governance. However, these actions were not yet embedded.
 

The provider did not always work effectively in partnership with other organisations to ensure care was coordinated and met people’s needs
Partners raised concerns about the provider’s openness, responsiveness and information sharing. Leaders did not demonstrate how they used partner feedback to improve collaboration. This reduced assurance that people’s needs were reviewed and updated in a timely way.
Partners also described difficulties building effective working relationships. They reported that the provider was not always open or transparent and could be difficult to engage with. One partner told us” When I visit, the provider is quite closed, I am asked to go to a certain area to wait for senior. I am not supported to look round and see people, I feel they don’t want me there and are very quick to get rid of me”. This limited shared understanding of people’s needs and care arrangements.
Leaders did not demonstrate consistent oversight of partnership working or show how they used partner feedback to improve collaboration. This reduced opportunities for joined up working and coordinated care.
However, staff worked with external professionals to support people’s day-to-day healthcare needs. Staff made referrals where required, and relatives confirmed communication about appointments and health concerns was generally maintained.
 

The provider did not demonstrate an effective or embedded approach to learning, improvement or innovation. Leaders did not use governance systems, feedback or resources to drive continuous improvement.
Leaders did not demonstrate how they acted on opportunities to improve systems and practices. A staff member told us they had requested system improvements, including an electronic medication management system, however, leaders did not provide evidence to show how they considered, evaluated or progressed this request. Leaders did not provide evidence to show how they evaluated or implemented system improvements to enhance safety and efficiency.
Leaders did not use oversight processes to support learning or improvement. Although senior leaders were present in the service and completed audits, this did not translate into clear learning, development or sustained improvement. This reduced opportunities for reflective practice and service development.
Leaders did not demonstrate how they analysed feedback, incidents or concerns to identify themes or drive change. Systems to evaluate the impact of improvements were not robust, which meant leaders could not demonstrate sustained improvement over time.
Staff feedback indicated they were not confident that raising ideas or concerns would lead to meaningful change. This limited engagement and reduced opportunities for collective problem-solving and innovation.