St David's Care 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.

This is the first assessment for this service. This key question has been rated requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulations in relation to premises and equipment and staffing.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were systems for learning when things went wrong. However, several staff told us when they alerted the management team to concerns about safety, these were not always acted on. For example, a member of staff explained they had raised concerns about a person’s mobility to the registered manager. They told us no changes were made to the person’s care and the person subsequently fell. They commented, “This incident may have been better managed and potentially prevented if concerns had been taken seriously.” We shared this information with the provider so they could take action to improve systems to respond to concerns from staff and professionals.

There were procedures to report and respond to accidents, incidents and safeguarding concerns. The provider’s records showed changes had been made following recent incidents. For example, updating staff training and reviewing people’s care plans. Lessons learnt were discussed in staff meetings to ensure they worked consistently and understood changes in procedures.

The provider did not always ensure pathways and transitions were well managed or safe. Nurses explained they did not always get sufficient notice about a new person moving in, did not have enough information about their needs and people sometimes arrived during busy times of the day. This meant nurses could not carry out observations or ensure the person was safe and settled in the home. Comments from staff included, “The protocol for admitting residents is not followed. A new resident can turn up in the middle of the medicines round”, “Sometimes we are told about a new admission mid-morning and they arrive at 2pm” and “Sometimes we do not have the preadmission information before a new person arrives.”

A person who had moved to the service, explained when they first arrived staff did not have information about their condition or needs. They did not have the right equipment to ensure the person was safe and their needs were met.

Failure to carry out safe transitions to the home placed people at risk of receiving unsafe or inappropriate care.

Representatives of the provider told us they had robust systems for assessing new people and supporting safe transitions to the service. They explained that the timing of admissions was sometimes decided by external parties and they did not control this. They also explained they had systems for reviewing care plans and assessments following admissions to the home to ensure any gaps in information were identified and risks to people’s safety were mitigated.

There were systems to ensure hospitals and other services had enough information about people when they moved from the home or were admitted to hospital. The care planning system included a ‘hospital pack’ which outlined people’s needs and how they communicated.

There were systems to safeguard people from the risk of abuse. Staff undertook training to understand about safeguarding adults. They were able to explain how to recognise and report abuse. The provider worked in partnership with the local safeguarding authority and other agencies to investigate and respond to allegations of abuse. They had taken steps to help reduce the risk of avoidable harm.

People using the service and relatives felt safe. They knew what to do if they were concerned about abuse.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. The provider requested legal authorisations where restrictions amounted to a deprivation of liberty for people who did not have the capacity to consent to these. Decisions about people’s care were made in their best interests and for their safety.

The provider did not always have a proactive response to managing risks. Staff had alerted managers to concerns about processes, lack of equipment and potential risks for individuals. Whilst action was taken after things went wrong, there was not always enough preventative action. During our assessment, a relative discussed concerns that a person was at risk of choking. Another person chose to take part in an activity that put them at risk of skin damage. There were insufficient risk management plans for these people. We discussed these with the registered manager. They immediately updated risk assessments and management plans.

Where the provider had identified risks, they assessed these and developed risk management plans. These were clear. They were regularly reviewed and updated. Risk assessments reflected good practice guidance about specific areas of care and incorporated professional advice.

Staff supported people in a safe way. For example, supporting people to move, and to eat and drink using safe techniques. Staff undertook training to understand about providing safe care.

Risks within the environment had not always been safely managed. The provider commissioned a fire risk assessment which took place in April 2026. The assessment identified risks including inadequate protection against the spread of fire and problems with escape routes and emergency lighting. The provider had a plan to address the issues. However, not all improvements had been made at the time of the assessment. Their plan did not include systems to reduce risk, such as increased staffing at night, whilst work was being completed.

The premise and equipment were not always suitable or safe. There had been problems with the hot water supply. The provider had a plan to resolve this, and the registered manager told us the impact on people was minimal. However, staff and people using the service told us there was significant impact. They explained that people could not have showers at times they wanted. Comments included, “It takes 2 hours for the water to heat up, my care worker is a dab hand at the bucket and bowl, but I would prefer a shower”, “There is an ongoing issue with hot water and it sometimes affects the whole unit” and “There is no hot water until 9am and this impacts residents and daily routines.” Staff and people using the service told us this meant staff sometimes carried bowls of hot water through the building and boiled kettles to wash people. The provider had assessed this practice and told us they had taken steps to mitigate risks associated with this.

Staff and professionals told us there was a lack of essential equipment, and that some equipment was not safe. A professional told us, “I have raised concerns about the new recliner chairs. These do not have brakes and are not fit for purpose. I have also requested another [mobile sit-to-stand transfer aid]. At present staff must borrow from other units.” Staff told us they had to share equipment between different units, such as hoists and scales. They told us this made it difficult to meet people’s needs in a timely way. Senior managers responded by telling is that equipment was occasionally moved between units to meet changing operational departs or individual needs. They told us they did not believe there was a lack of equipment, and they were able to provide safe care.

We identified further concerns with the state of repair and safety in the building. The provider had a plan for renovation and redecoration. Some areas of the building had recently been renovated and had new flooring.

There were not enough staff deployed to meet people’s needs and to keep them safe. People using the service, relatives and staff told us staffing shortages meant people sometimes waited for care or their needs were not met. Multiple people told us they sometimes waited over 30 minutes for staff to help when they needed this. Comments from people and relatives included, “Our main concern is they are consistently short staffed”, “Staff struggle at times. Especially at weekends. It takes them a while to help [person]” and “There are not enough staff. Care workers are rushed and care is task based.”

Short notice absences were not always covered. This included when staff were taken off shifts for training. Comments from staff included, “The residents on my unit have very high needs. Many require 2 care workers. The rota is not well managed, and we do not always have enough staff”, “Night staff are regularly expected to manage large numbers of residents with insufficient staffing levels or support”, and “I am deeply concerned about unsafe staffing decisions made on a regular basis.”

During the day many people spent time in the activities room taking part in a group activity. However, staff and relatives told us additional care staff were not deployed to this room to assist people with drinks and care needs, meaning the activities coordinators had to support people and run the activities.

A relative explained they had recently witnessed a person in distress. They called for help and used the emergency alarm, but staff did not attend.

There were systems to carry out checks on staff during recruitment. New staff undertook an induction and completed a range of training. Managers assessed staff competencies. There were systems to provide supervision and appraise staff work. However, staff told us they did not always have thorough inductions for their roles which enabled them to feel confident. Staff explained they did not feel supported or have enough opportunities to discuss their work with line managers.

There were systems to help prevent and control infections. Staff completed training to understand about these. Managers and nurses met to discuss clinical care and how acquired infections were being monitored and managed. There were schedules to ensure the environment and equipment were clean. Managers undertook audits of cleanliness. Staff were provided with personal protective equipment (PPE) to use when needed.

People using the service told us they thought the standard of cleaning was good. Their comments included, “I see a cleaner most days. It is tidy enough” and “The cleanliness is good. They are constantly cleaning. Staff use gloves and aprons.”

There were appropriate systems for laundry, kitchen hygiene and waste disposal.

There were systems for the safe management of medicines. Medicines, including controlled drugs, were stored securely and at appropriate temperatures. People’s medicines were administered as prescribed. Some people were administered medicines covertly (without their knowledge). Staff carried out appropriate assessments and involved the necessary individuals including the GP and next of kin to ensure this was done safely.

Staff created person-centred care plans to support people with their medicines. Some people were prescribed medicines to be administered on a when-required basis for health conditions and pain. There was guidance in care plans and protocols for these medicines to be administered consistently.

The local GP practice regularly reviewed medicines for people.

There was a medicine policy in place. There was a process in place to report and investigate medicine errors and incidents. Staff carried out medicine audits to identify gaps and make improvements. Staff received training and managers assessed their competency to handle medicine safely.