CQC report explained · a residential care home
What the CQC found at St Davids Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- The home had improved physical safety measures and infection control in several areas. However, inspectors were not assured about safe admissions, up-to-date infection policies or all visitor checks.
- Effective?
- Requires improvement
- This question was not assessed during the targeted inspection.
- Caring?
- Good
- This question was not assessed during the targeted inspection. Inspectors observed people interacting with staff and found that people felt able to raise concerns.
- Responsive?
- Good
- This question was not assessed during the targeted inspection.
- Well-led?
- Requires improvement
- Governance systems had improved, with monthly audits and safety checks in place. Some policies and processes were still being embedded and needed updating.
What inspectors found, January 2022
Overall rating remained Requires Improvement; inspectors found improvements in safety and governance, but infection control systems were not fully up to date.
This was an unannounced targeted inspection on 7 December 2021. One inspector checked whether the home had met a warning notice about governance. Infection prevention and control was also reviewed.
The home had improved its environment and safety measures. Changes included safer window restrictors, radiator adaptations and safer gates near stairs. People appeared comfortable speaking with staff and one person praised the food and care.
Inspectors found that governance systems had improved and the previous warning notice had been met. However, some systems were still being put into practice. Infection policies and admission testing arrangements did not fully follow current guidance.
The overall rating remained Requires Improvement from the previous inspection. Safe and Well-led were inspected but not rated because this visit only covered specific concerns, not the full questions.
Improved physical safety
The home had made changes to reduce risks from scalds, falls from height and stairs. Safety checks were also identifying issues that needed attention.
“Changes had been made for example regarding the installation of window restrictors and adaptations to the radiator covers and gates on the landings leading to flights of stairs, to improve safety.” from the report
People could speak openly
People felt comfortable giving feedback and could approach the provider about concerns. Inspectors also observed active interaction between people and staff.
“People we spoke with felt comfortable speaking openly in front of staff to give us feedback about the standards of care provided.” from the report
Better governance
The provider had introduced additional checks and monitoring since the last inspection. The warning notice about governance had been met.
“At this inspection enough improvement had been made and the provider was no longer in breach of regulation 17 and had met the requirements of the warning notice.” from the report
Some infection controls were working
Inspectors were assured about several areas, including PPE, testing, social distancing, hygiene and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Admission testing
seriousInspectors were not assured that the home was following the required enhanced testing arrangements when admitting people. This could affect how new and existing residents were protected.
“We were not assured that the provider was admitting people safely to the service.” from the report
Out-of-date infection policies
needs fixingThe infection prevention and control policies had not been updated after changes to COVID-19 guidance or the recent outbreak.
“The information contained within the policies and procedures was out of date and had not been reviewed in line with changes in COVID-19 guidance, or as an outcome of a recent outbreak at the service.” from the report
Some checks still being embedded
needs fixingGovernance arrangements had improved, but not all systems were consistently established. The fire risk assessment and infection-related policies also needed updating.
“The governance systems the provider had in place to assess, monitor and improve the quality and safety of the service had improved since the last inspection, but aspects were still being embedded into practice.” from the report
- 01What changes have been made to ensure enhanced testing is completed safely when people are admitted?
- 02Have the infection prevention and COVID-19 policies now been updated to match current guidance?
- 03How do you check that visiting requirements, including vaccine status checks, are followed every time?
- 04Has the fire risk assessment been updated to reflect the changes to access around the stairs?
- 05How do monthly audits identify and resolve problems, and how do you check that improvements stay in place?
This was a targeted inspection of specific concerns under Safe and Well-led, including infection control; it did not reassess the full five key questions, so the previous overall Requires Improvement rating remained. This explanation was written from the published report of 14 January 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2021
St Davids Residential Care Home was rated Requires Improvement; inspectors found safety, infection control and management problems, although there were improvements and caring staff.
Inspectors visited on 6 and 10 May 2021. They spoke with people, relatives and staff, and checked care records, medicines, recruitment files, training information and management audits. The inspection was prompted by concerns about staffing, risk management and quality of care.
The home was not always safe. Inspectors found risks from hot radiators, hot water, unsecured furniture, unsafe window restrictors and accessible stairs. COVID-19 precautions were not fully followed. Some people were left without stimulation for a long time because staffing was not enough at certain times.
There were also positive findings. People generally received their medicines, food, drink and healthcare. Staff were trained and recruited safely, and people were supported with mental capacity and best-interest decisions. Relatives and staff often described the care and atmosphere positively.
The overall rating was Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. The home had received the same overall rating at the previous inspection in October 2019 and remained in breach of regulations, although some earlier problems had improved.
Food and healthcare
People's nutritional and healthcare needs were met. The home supported access to several healthcare professionals and monitored people's weight.
“The service supported people to access a variety of healthcare services including the GP, opticians, district nurses, the hospital and chiropodist.” from the report
Staff training and recruitment
The home had completed appropriate recruitment checks. Staff received training, supervision and appraisals.
“Records showed that staff received regular training, supervisions and appraisals.” from the report
Mental capacity practice
The home had improved its approach to consent and best-interest decisions. Relatives were involved where appropriate, and applications for liberty safeguards were made when needed.
“Best interest decisions had been made with appropriate people such as relatives being part of those discussions and decisions.” from the report
Environmental safety
seriousPeople were exposed to risks from hot surfaces and water, unsecured furniture, unsafe window restrictors and accessible stairs. The manager took prompt action after inspectors raised these concerns, but the provider remained in breach.
“People had been put at risk from scalds and burns.” from the report
Infection control
seriousSenior managers did not always wear face masks, and staff were not checked for COVID-19 symptoms when they first entered the home. Inspectors said this increased the risk to clinically vulnerable people.
“The service was not fully adhering to government guidance in relation to managing COVID-19 and this put clinically vulnerable people at higher risk of becoming seriously unwell.” from the report
Staffing and meaningful activity
seriousSome staff said more night staff were needed. Inspectors saw people left in one position without stimulation, and one person's required observation did not take place.
“We saw that people who wished to rise early were left in one position, without stimulation, for a long period of time.” from the report
Weak management checks
seriousAudits had identified unsafe water temperatures but no action had been taken. Other checks missed unsafe furniture, window restrictors and incomplete infection control arrangements.
“The governance system the provider had in place to assess, monitor and improve the quality and safety of the service had not been fully effective at identifying and rectifying concerns.” from the report
- 01What has been done to make the hot water, radiators, furniture, window restrictors and stair guards safe, and how are these checks recorded now?
- 02How many staff are scheduled overnight, and how will you make sure people who rise early are supervised and offered meaningful activity?
- 03How are staff and managers now checked for COVID-19 symptoms on entry, and are face-mask requirements being followed?
- 04What changes have been made to the governance system after the Warning Notice, and who checks that identified problems are corrected?
- 05How will relatives be kept involved in care planning and informed about changes or concerns?
This inspection examined Safe, Effective and Well-led; the report does not give separate ratings for Caring or Responsive. This explanation was written from the published report of 11 June 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of St Davids Residential Care Home
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- January 2022Inspected but not ratedcurrent ratingSafe: Inspected but not ratedWell-led: Inspected but not rated
Read what inspectors found at St Davids Residential Care Home →
- June 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at St Davids Residential Care Home →
- October 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- January 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- June 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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