Compton House Christian Nursing Home

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 remained Good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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 proactive and positive culture of safety. Staff listened to concerns about safety and investigated and reported safety events. Staff understood their responsibility to report incidents and concerns. Staff documented accidents and incidents involving people and escalated concerns to the management team.

The registered manager had oversight of recorded incidents to determine whether changes to people support needed to be made. For example, the provider tracked and monitored people’s skin integrity to evaluate what treatment was in place and what actions were required. Incidents were monitored, and actions were recorded. For example, basic health observations were taken and falls and accidents were analysed to identify any trends and make necessary changes to areas such as staffing, equipment or the environment.

Risks were not overlooked, and care plans and risk assessments addressed any concerns over people’s mobility and health etc. Relevant referrals had been made to address any additional support people needed to stay safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place to facilitate safe pathways and transfers for people. Assessments of need and risk assessments were completed during the initial assessment of care to ensure safe, effective support. Peoples’ needs were assessed thoroughly on admission, using information from health partners, people and their relatives to ensure that risks were current and known to staff when care commenced. One person said, “I feel reassured being here."

Care plans detailed people's health conditions and provided staff with the guidance they needed to seek additional professional health support and when to make appropriate referrals to partners. Referrals had been made to specialist services such as the mental health team. Partners we spoke to were positive about the staff’s response to their guidance. One professional said, “They refer appropriately and follow advice, re-referring or contacting again as appropriate.

People were not always safeguarded to ensure that they understood their rights and were protected against discrimination under the Mental Capacity Act 2005 (MCA). The provider did not undertake decision specific mental capacity assessments for those who lacked capacity. We have detailed this within the Effective key question.

Staff had the training and knowledge to ensure they could recognise when people may be unsafe and to identify potential signs of abuse. Staff understood processes for reporting these concerns. Information about people’s care was protected by adherence to data protection policies and consent processes. The provider ensured that statutory notifications had been submitted to CQC, and the local authority were alerted to any potential safeguarding incidents. Statutory notifications are events and incidents that providers are required to inform us of.

The provider worked with people to understand and manage risks.

Risk assessments were detailed, person centred and provided detailed guidance for staff to manage these. For example, people identified at risk of choking received diets appropriate to their needs. Speech and language therapists (SaLT) advice was sought and included in people’s care plans. Risks of malnutrition and dehydration were supported by evidence-based tools to determine levels of risk and increased and consistent monitoring of food and fluid intake. Leadership conducted audits and quality assurance checks to ensure that staff practice remained safe.

Risks associated with the safety of the environment and equipment were identified and managed appropriately. Regular checks to ensure fire safety had been undertaken and people had personal emergency evacuation plans which informed staff of how to support people to evacuate the building in the event of an emergency. One person said, “Feel very, very safe. Very secure. Peaceful. All I need, I just have to ring the bell and (staff) come.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Regular maintenance checks of the environment were completed, while equipment was serviced and monitored.

The layout of the home supported people who required support from staff and equipment to mobilise around safely. Areas were accessible and people had lifts, clear signage and handrails to help them navigate where they wished safely.

Regular checks to ensure fire safety had been undertaken and people had personal emergency evacuation plans which informed staff of how to support people to evacuate the building in the event of an emergency.

Recruitment practices were not always robust or effectively monitored to ensure that staff continued to be safe to work with people.

Newly recruited staff received Disclosure and Barring Service checks to ensure they were safe to work. Processes were in place when new staff were waiting for their checks to be completed. However, the provider had not always ensured that some staff, who had been employed at the home for a number of years, had obtained updated checks with the Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Whilst there is no mandatory renewal date for DBS checks, it is best practice to renew these periodically to ensure safe recruitment practices. CQC recommends that providers consider when new checks are needed, evidenced by risk assessments, even if there are no changes in employment. The deputy manager told us that this was an area that needed addressing. We were made aware that for one staff member, there were no references on file, while another workers references had been sought but not followed up.

The provider had not always ensured that some training and skill development was maintained to meet the needs of some people. Leadership informed us that, under previous management, the home had stopped admissions for people living with dementia. Management and the provider confirmed that they wished to ensure that the environment was suitable for all residents and so processes could be put in place to safely achieve this. The registered manager had initiated a decision to restart these admissions, and the home occupancy had increased. The deputy manager said, “Dementia training is something we've picked up on.”

One staff member indicated that although staff received e-learning training in dementia, they felt staff did require more training around dementia and that it remained ‘a challenge’. The staff member commented that they felt that staff do not always know how to handle changing behaviours associated with dementia and may not always be certain if they're responding in the right way. The deputy manager told us that Namaste training was being undertaken in July 2025, while three staff members were being made dementia champions to support skills of staff. Namaste Care training equips carers with tools to enhance the quality of life for individuals with advanced dementia. Management had started to implement changes to improve support, but this needed time to be embedded.

There were enough trained staff in place to ensure people remained safe and meet their needs. People told us that staffing was generally consistent. New staff completed an induction and probationary period. Staff completed shadowing shifts with established staff members prior to working independently. Ongoing and comprehensive training was provided to ensure staff had the skills they needed. Where people had specific health needs, specialist training was provided. One person said, “I think they are well trained. My legs have blistered and swelled and need a bit of care. My legs are well taken care of by the nurses.” Another person said, “I know there are always qualified staff day or night.”

Systems and processes were in place to protect people and to prevent and control the risks of infection.

The service employed a number of measures to promote good infection prevention. Housekeeping staff maintained a consistent and thorough cleaning schedule of all areas of the service. Staff received training in infection control, health and safety and food hygiene. Staff had access to personal protective equipment (PPE) for when they carried out personal care and administering medicines.

All areas of the service were seen to be clean, tidy and smelt fresh. Staff presented professionally in their appearance and residents were nicely dressed, demonstrating staff took care and considered how people liked to present themselves. The leadership maintained oversight of infections people needed support with such as chest infections and eye infections. Processes were in place to treat these and prevent the spread of infection.

People spoke positively about staff actions to maintain a clean environment. One person said, “(Staff) come in every day and clean all round and over and even clean my trolley down.” Another person said, “They clean the rooms every day. It's always very clean.”

Systems and processes were in place to ensure that people’s medicines were administered safely. Effective processes, good medicines management and our observations confirmed this.

Medicines were administered by registered nurses. People’s medicines were managed, administered and stored safely by nurses and team leaders. Medication Administration Records (MAR) showed that people received their medicines as prescribed, and these records were completed accurately. PRN protocols were in place for medicines which were prescribed on a ‘when required’ basis.

We observed a series of medicines being administered which was completed safely and effectively. The staff member was patient and diligent to ensure that medicines were given safely and in line with people’s wishes. Leaders had oversight of medicine administration and completed regular audits and competency assessments to ensure they were administered safely.