Archived: Compton Manor Residential Care Home

Compton Manor is a residential care home providing personal care to up to 38 people. The service provides support to older people and younger adults, some of whom have diagnoses of dementia. At the time of our inspection there were 35 people using the service.

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

There was a friendly atmosphere in the home and staff supported people in a kind and caring way that took account of their individual needs and preferences. People and their families were supported to express their views and be involved in making decisions about their care and support.

People and relatives spoke positively about the service and told us improvements had been made since our last inspection. People were protected from the risk of avoidable harm. Medicines were managed safely. The risks to people's safety and wellbeing had been identified, assessed, and managed. Accidents and incidents were investigated and information about these was shared with the local authority. There were procedures in place for preventing and controlling infection, and the staff followed these. Staff were recruited safely, and robust pre-employment checks were completed.

People were supported by staff who had regular training to gain the skills and knowledge necessary to provide effective care. Staff skills and knowledge were reviewed through regular supervision and competency checks. People ate a diet based on their individual preferences and requirements. People had good support to access the healthcare services they needed.

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 were supported to undertake activities of their choice and told us they enjoyed these. Staff engaged well with people to find out what they wanted to do. Staff understood and respected people’s individual cultural, religious, and spiritual needs.

Staff told us they that they enjoyed working there and felt supported by the registered manager and provider. The provider and registered manager were promoting an open, empowering, and inclusive culture within the service. There were a range of systems in place to assess and monitor the quality and safety of the service and to ensure people were receiving appropriate support, but these processes required more time to become fully embedded in the service. The registered manager took prompt action when any areas for improvement were identified.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 20 April 2022).

At our last inspection we found breaches of the regulations in relation to the assessment of risks to individuals, the safety of the environment of the home, the governance of the service and the providers statement of purpose was not up to date. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve and provided us with monthly updates.

At this inspection we found improvements had been made and the provider was now meeting these regulations.

Why we inspected

We carried out this inspection to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

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

Compton Manor Residential Care Home provides accommodation and personal care for up to 38 older people, including people who live with dementia. At the time of our visit 25 people lived at the home and one person was in hospital. Accommodation is provided in an adapted building across two floors, with communal areas on the ground floor.

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

People felt safe. However, individual and environmental risk was not consistently assessed and well-managed. This demonstrated lessons had not always been learnt. Some areas of medicine management required further improvement. Procedures were in place to keep people safe and staff understood their responsibilities to protect people. Staff were recruited safely and there were enough staff on duty to meet people’s needs.

The provider had not taken the action needed to ensure compliance with the regulations. Despite the introduction of structured quality audits and checks, issues we found had not been identified. The prevention and control of infection was not always managed safely and in line with government guidance. The manager had developed positive working relationships with staff and other professionals and demonstrated their commitment and determination to drive improvement. Relatives and staff felt positive change was taking place.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 06 September 2021) and there were breaches of regulation. Conditions were imposed on the provider's registration which required them to provide us with monthly reports on how they were meeting the regulations. At this inspection not enough improvement had been made. The imposed conditions remain in place and the provider continues to be in breach of three regulations.

This service has been in special measures since 06 September 2021. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in special measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 28 June 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Compton Manor Residential Care Home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified continued breaches in relation to risk management, the prevention and control of infection and how the service is managed at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will continue to require a monthly action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Compton Manor Residential Care Home provides accommodation and personal care for up to 38 older people, including people who live with dementia. At the time of our visits 31 people lived at the home. This included two people in short term discharge to assessment beds which are used to support timely discharges from hospital. Accommodation is provided in an adapted building across two floors, with communal areas on the ground floor.

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

Ineffective governance and lack of provider oversight meant previously demonstrated standards and regulatory compliance had not been maintained. The provider’s systems and processes designed to identify shortfalls, and to drive improvement were not effective and had not identified the concerns we found. This demonstrated lessons had not been learnt. The provider’s policies and procedures were not fit for purpose. The provider had not ensured the manager had the guidance they needed to fulfil their role. Despite this the manager felt supported through telephone contact with the provider.

The prevention and control of infection was not managed safely and in line with government guidance. Risk associated with people’s care, the environment and fire safety were not consistently identified and well-managed. The provider was not able to demonstrate all staff were recruited safely and some staff did not understand their responsibilities to keep people safe. Whilst records showed medicines were safely managed, staff medicines refresher training was out of date. Action was taken to address this. Despite our findings people told us they felt safe.

Records indicated some staff had not completed an induction and staff training was not up to date. Action to address this was planned. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People and relatives described staff as caring and friendly. Staff demonstrated a caring attitude. However, staff were task focused and did not always promote people’s rights. Despite our findings people felt respected by staff who promoted their independence.

Care was not always provided in line with people’s assessed needs. Care plans contained limited information about what was important to people and some contained out of date and conflicting information. Daily records were disorganised and had not been completed to demonstrate planned care had been provided. Action was planned to address this. People and relatives felt able to raise complaints and concerns. People could choose to take part in some individual and group activities.

Staff were supported by a manager who was approachable and supportive. Some staff did not feel valued or supported by the provider. The manager had identified some areas for improvement and acknowledged they needed additional support to achieve this. Despite our findings people and relatives were satisfied with the service they received and felt recent management changes had resulted in improvements being made. Staff shared this view.

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

Rating at last inspection

The last rating for this service was good (published 7 March 2018).

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The inspection was prompted in part due to concerns received about governance, provider oversight of the service and poor infection control practices. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We identified breaches in relation to provider oversight, the identification and management of risks associated with the prevention and control of infection, and the environment including fire safety.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special measures

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Compton Manor is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home provides residential care to older people, including people who live with dementia. The home has two floors accommodating up to 38 people in one adapted building. On the day of our visit 35 people lived at the home, including two people on a short stay. One person was in hospital. The home is located in Coventry in the West Midlands.

At our last inspection in January 2016 we rated the home Good. At this inspection we found the evidence continued to support the rating of Good overall. However, improvement was required to some of the provider’s systems and processes for monitoring the quality of the service.

This inspection report is written in a shorter format because our overall rating of the home has not changed since our last inspection.

There was a registered manager at the home who had been in post since September 2017. 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.

The providers systems to monitor the quality and safety of the service provided were not consistently followed and some audits were not effective. Despite this, people, relatives and staff felt the registered manager was approachable and the home was well-led. The registered manager was developing their knowledge and understanding of their management responsibilities and regulatory requirements.

People told us they felt safe living at Compton Manor. Staff understood how to protect people from harm, and provided good support to reduce identified risks. Medicines were managed safely. Information in care records ensured staff had the detail needed to ensure care and support was provided in line with people’s needs and preferences.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the home supported this practice. People and their relatives were involved in planning their care, and people decided how they wanted to live their lives on a day to day basis.

People enjoyed their meals and the varied range of choices available to them. They were supported to access healthcare professionals when needed. Staff respected people’s privacy and promoted their dignity by supporting people to be independent. People and relatives spoke highly of staff who they felt were helpful, kind and generous.

People were supported to maintain relationships with people who were important to them. Family and friends were welcomed to visit the home at any time. A range of meaningful activities were available which people could choose to take part in. People were supported to follow individual interests and hobbies.

People, relatives and professional visitors were complimentary about the quality of care provided and were invited to share their views about the home to drive forward improvement. Complaints were managed in line with the provider’s procedure.

Staff enjoyed working at the home and felt supported and valued by the management team. Action was being taken to make improvements to the home’s environment.

Further information is in the detailed findings below.

Compton Manor is a care home providing personal care and accommodation for a maximum of 38 older people. The home is located in Coventry in the West Midlands. There were 27 people living at the home at the time of our visit. A number of people were living with dementia.

The service had a registered manager. This is a requirement of the provider’s registration. 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. We refer to the registered manager as the manager in the body of this report.

People told us they felt safe at the home, and staff treated them well. Staff knew how to safeguard people from abuse, and were clear about their responsibilities to report any incidents to the manager. The provider had effective recruitment procedures that helped protect people, because staff were recruited that were of good character to work with people in the home.

There were enough staff at Compton Manor to support people safely. Staffing levels enabled people to have the support they needed to take part in interests and hobbies that met their individual needs and wishes. People who lived at the home were encouraged to maintain links with friends and family who could visit the home at any time.

The manager understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The manager had made DoLS applications when any potential restrictions on a person’s liberty had been identified. People were able to make everyday decisions themselves, including how they spent their time and the activities they might enjoy, which helped them to maintain their independence.

People were supported to attend health care appointments with health care professionals when they needed to, and received healthcare that supported them to maintain their wellbeing. There were processes in place to ensure people received their prescribed medicines in a safe manner.

All of the care records we looked at were up to date and described people’s routines and how they preferred their care and support to be provided by staff. People and their relatives were involved in planning, and reviewing how they were cared for and supported. Risk to people’s health and welfare were assessed and care plans gave staff instruction on how to reduce identified risks. Staff had a good knowledge of the people they were caring for. People and their relatives thought staff were caring and responsive to people’s needs.

Staff said they were supported and listened to by the management team. Staff received the training necessary to give them the skills they needed to meet the needs of people they cared for. Staff reassured and encouraged people in a way that respected their dignity and promoted their independence. People were given privacy when they needed it.

People and relative’s told us they knew how to make a complaint if they needed to. However, no-one had made a complaint regarding the home

The provider had established procedures to check the quality and safety of care people received, and to identify where areas needed to be improved. People and relatives were encouraged to develop the service by providing feedback about the quality of the service they received and how the home was run. The manager gathered feedback from people, their relatives and staff through meetings or quality assurance questionnaires. Improvements were made in response to people’s suggestions.

People, relatives and staff felt the management team were approachable. The manager maintained an open culture at the home and was committed to continually improving the service provided. There was good communication between people, staff members and the management team.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

We found people's care records had been regularly reviewed by a member of staff. We saw people's care records reflected their care needs.

We saw people had risk assessments in place that made sure risks to their health and wellbeing were managed.

We looked at staff records and found the provider's recruitment practice was safe and thorough.

People were cared for in an environment that was clean and hygienic.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We were told nobody who lived at the home was under a Deprivation of Liberty Safeguard.

Is the service effective?

People told us the care they received met their needs. When talking about the staff people told us they were, 'Good', 'Supportive' and 'Helpful.'

Staff we spoke with had a good understanding of the needs of the people they supported and what they told us was reflected in people's care plans.

Is the service caring?

We spoke with eight people who used the service and they were all positive about the staff who supported them. One person told us the staff were, 'Nice and sociable.'

Staff we spoke with were positive about their role as care workers.

Is the service responsive?

We found people were asked for their views about their care and these were acted on. We saw the provider had sent out an annual relatives and resident's satisfaction survey in 2013. The results we saw from the survey were positive.

We saw incidents and accidents had been responded to and actions had been taken to make improvements following investigations.

People's needs and abilities were assessed before they moved into the home. The care plans we looked were regularly reviewed and changed as people's needs changed. We found staff supported people to see other health professionals, such as doctors, dentists and opticians when they needed to.

Is the service well led?

We found the service had an effective quality assurance system in place and any identified actions had led to improvements in the service people received.

People who used the service told us they were able to speak with the manager and felt able to raise any issues or concerns they had.

We found evidence improvements had been made to the service following investigation of concerns.

Staff we spoke with were very positive about working at the home. Most staff had worked at the home for several years. Staff showed a good knowledge of the needs of people in the home.

We observed interactions in the home and looked at a sample of care records. We saw staff were attentive to the needs of people in the home, consulted them and explained what was happening. We frequently heard staff ask questions such as 'Where would you like to sit now?' 'Can you move your legs?' and 'You look a bit stiff ' are you alright? '. We saw that staff enjoyed a good rapport with people who lived at the home. In many instances, staff had worked with some people for several years.

The wide range of food at mealtimes showed that the home provided choice and responded to individual preferences.