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St. David's Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 15 January 2020

About the service

St David’s Home is a nursing home providing personal and nursing care for up to 76 adults living in four units. One unit is used to provide rehabilitation support to people with a range of physical disabilities with the aim of being able to live a more independent life and to return to their home or move to other accommodation. At the time of the inspection there were 71 people staying at the home. The home is operated by St David’s Home For Disabled Soldiers, Sailors and Airmen, a registered charity.

People’s experience of using this service

People and relatives told us they felt safe living at the home. However, the provider had not always assessed, monitored and managed risks to people’s safety in the home environment. The provider did not ensure the hydration needs of some people were always being met.

Most people and relatives said staff were caring and treated people with dignity and respect.

People's care plans provided some information about the care tasks they needed staff to complete. However, these plans did not provide personalised information about people, their background, their preferences for their care, or their communication needs. The provider had started to introduce a new care plan format to better record this information.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; there were policies and systems in the service to support this practice but these were not implemented consistently.

There were systems in place to monitor the quality of the service and recognise when improvements were required. These were not sufficiently robust to have identified and addressed the issues we found at this inspection. The new manager had introduced some new systems to improve the quality of service.

Staff and volunteers provided people with a varied programme of activities throughout the day, which also included trips out into the local community.

Staff supported people to maintain their health and access other healthcare services when required. People were also supported by a team of occupational therapists and physiotherapists employed by the provider to help them to maintain their health and independence.

People were supported at the end of their life to have a comfortable and dignified death.

People knew how to make a complaint or raise a concern and the provider responded to these appropriately.

Staff received an induction, training and periodic supervision. Staff said the managers were approachable and told us they felt supported.

For more details, please see the full report which is on the CQC website at

Rating at last inspection:

The last rating for this service was good (published 26 July 2017).

Why we inspected

The inspection was prompted in part due to concerns received about how people were supported to be safe from the risk of abuse and harm or poor care. A decision was made for us to inspect and examine those risks.


We have identified breaches in relation to providing safe care and treatment, medicines management, meeting people’s nutritional needs, seeking people’s consent appropriately, dignity and respect, person-centred care, and good governance.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider, the local authority and Clinical Commissioning Group to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 15 January 2020

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 15 January 2020

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 15 January 2020

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 15 January 2020

The service was not always responsive.

Details are in our responsive findings below.


Requires improvement

Updated 15 January 2020

The service was not always well-led.

Details are in our well-Led findings below.