St David's Care Home

The service was registered with CQC on 9 July 2024, and this was the first assessment. The service was previously managed by a different registered provider. Following this assessment, we have rated the service requires improvement.

We identified breaches of legal regulations relating to premises and equipment, good governance and staffing.

The provider’s systems for managing the service and monitoring risks were not always effective. Staff did not feel empowered to speak up. They told us when they did, their concerns were not always acted on. Some people and relatives felt there were not enough opportunities to speak with managers. Failure to ensure all staff felt able to speak up, without fear of negative consequences, and failure to and act on the feedback from staff and other stakeholders, placed people at increased risk of inappropriate and unsafe care.

The environment was not always safe, suitable or well-maintained and the provider had not always recognised when things needed to change. For example, identifying environmental risks or understanding the impact of these for people. This meant people did not always receive person-centred care which reflected their needs.

The provider did not always deploy enough staff to meet people’s needs in a person-centred way. People experienced delays in receiving care and support. They were not always able to do the things they wanted to do. This impacted on their emotional wellbeing.

Staff did not always feel supported by managers.

There were systems to involve people, but not everyone felt these were followed and wanted more information and opportunities to give feedback.

Staff assessed people’s needs and worked with external professionals to help make sure these needs were met. However, staff felt assessments were sometimes rushed when people first moved to the home, increasing the risk they would not receive the right care. Representatives of the provider told us they had robust systems for assessing new people and supporting safe transitions to the service.

Staff monitored people’s wellbeing and responded when they identified changes in people’s needs. Although staff and professionals felt concerns they highlighted to managers about equipment were not always acted on.

Staff completed a range of training and provided evidence-based care and support. People received their medicines in a safe way.

The provider carried out a range of audits. When these audits identified issues, the provider took action to address these. However, audits were not always effective at identifying where improvements were needed.

There were systems for staff to learn from accidents, incidents and complaints. The provider investigated allegations of abuse and worked with the local authority to help protect people from avoidable harm. The provider ensured legal authorisations were in place where decisions about people’s care amounted to a deprivation of liberty.

We discussed our findings with the registered manager and senior managers. They were already aware of some of the concerns and had started to make improvements. We have asked the provider to complete an action plan telling is how they will make the required improvements.