St Mungo's Broadway - 2 Hilldrop Road

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 changed to 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 Regulation 12 (safe care and treatment). People were not always protected from the risks that could arise if people’s medicines were not managed safely at the service.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

During this assessment, we identified some issues with how medicines were stored and recorded. These issues had been identified at our previous assessment in January 2024 and had been partially but not fully addressed.

The temperature of the room and the fridge where staff kept medicines were not monitored as required. Therefore, there was a risk that the effectiveness of medicines would be affected due to being stored at too high or low temperatures. Following the assessment the provider told us that they have introduced new arrangements to make sure the temperature at which medicines are stored is appropriately monitored.

Stock checks of medication occur three times a week. It is staggered over the week. Ten people have their medication stocks counted every 2 days. This means that everyone has at least a weekly count of their medication to keep a check on how much is available and when new supplies need to be obtained.

The provider did not ensure that only authorised trained and competency assessed staff had access to medicines storage. During our visit, we observed a member of care staff accessing one medicine cabinet, when they were not authorised to do so. Staff told us this was an agreed practice for this person. However, this meant this person potentially had access to all people's medicines, which was an unsafe practice. After our visit the provider informed us about the action they had taken to address training for staff who could then administer medicines. We will verify the effectiveness of these actions at our next assessment.

We saw that the administration of controlled drugs was not accurately recorded in people’s records. This meant that people might not have received their medicines as prescribed. Since our assessment in July 2025 the provider has told us that, after our feedback, they had implemented an audit for staff to ensure that they sign for, and record, the controlled medication record daily to ensure there were no errors. We will verify the effectiveness of these actions at our next assessment.

At the time of this inspection, we found that the stock of when required medicines were stored in a filing cabinet which was not in line with the provider’s policy. Furthermore, the controlled drugs cupboard was not secured in line with legislation. This meant people were not protected against risks that can arise if medicines are not stored appropriately. Following this assessment the provider reported that they have purchased new trolleys to store medicines and secured medicines cabinets which had not previously been properly secured. We will check this again at our next assessment.

The provider conducted medicine’s audits. Whilst the service completed regular medicines management audits, these had identified some of the areas of concern that were raised during our assessment visit. In addition, concerns regarding medicines management that had been identified during previous audits and inspections had still not been fully addressed. Following the assessment the provider told us about the measures that they had introduced to address these areas, which we will verify at our next assessment.