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

During our assessment of this key question, we found concerns around the management of people's medicines, which resulted in a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can find more details of our concerns in the evidence category findings below. Staff protected people from the risk of abuse. They followed safeguarding procedures and received appropriate training. Staff understood their roles in reporting safeguarding concerns. We observed staff engaging in positive and kind interactions with people. Evidence showed that the service assessed risk to people's health and well-being and the environment people lived in as required.

This service scored 62 (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.

Staff understood their responsibility to safeguard people from abuse. They knew what action to take if they thought people were at risk of harm. The service manager confirmed that staff were proactive in taking action when they were concerned about people's wellbeing.

The service had a safeguarding policy in place. However, we noted it was not updated within the last 12 months. All staff received regular training on how to safeguard people from abuse. Safeguarding concerns were regularly discussed with staff in staff meetings and daily handovers. Staff also spoke about safeguarding matters with people in periodic residents’ meetings and one-to-one conversations with them. Applications for Deprivation of Liberty authorisations had been made appropriately.

People said they felt safe with both staff and other people using the service. They told us they always felt there were enough staff around to support them. People said they were comfortable raising concerns and would do this with the care staff or the service manager.

Some people we spoke to felt they would like more involvement in making decisions around some aspects of care and risk management, for example, cigarettes and alcohol use and how their personal finances were managed. All the people we spoke with felt well involved in other areas of their care, including changes to care plans and risk assessments.

The service manager and staff told us they involved people in assessing and managing risks to their health and well-being as much as possible. Some staff we spoke with felt that they would benefit from more training on dealing with issues and behaviours specific to this service user group, for example, risk reduction strategies around alcohol use.

During our onsite visit, we observed that staff supported people in line with their needs.

We saw that care records contained guidance for staff to support people safely when they were at risk. Records of resident meetings showed that staff involved people in discussions on risk management and how staff and people could manage those risks.

There were systems in place to ensure people lived in a safe environment. We saw evidence of regular health and safety checks, cleaning checklists, and equipment maintenance records.

We observed that the service was clean and well-maintained. We noted that in the instance of one spillage that happened during our visit, staff did not take prompt action to address it. We spoke about this with the service manager, who took immediate action and the risk of slip was removed. People we spoke with confirmed that they were happy with the standards of cleanliness at the service. Therefore, overall, we were assured that people were living in a clean and safe environment.

On the day of the assessment, we saw that there were enough staff members on duty to meet people’s needs. We observed staff being kind and friendly with people. The atmosphere at the service was pleasant and positive.

Staff told us they undertook regular mandatory training and could access additional training from St Mungo's on areas of their specific interest. All staff knew how to access the provider's training portal and make training requests. Staff said that supervision took place regularly, and they felt they could bring up any concerns they had. Staff reported they felt able to approach the service management at any time and that they were listened to.

People we spoke with expressed that the staff looked after their well-being well. They said that staff knew how to meet people's care needs.

The provider's head office completed the staff recruitment process and checks. Therefore, the recruitment documentation was unavailable during our onsite visit, and we did not review it on this occasion. The service manager told us they filled all care staff vacancies with permanent staff. The service at times used agency staff when people's needs increased or for night shifts. Those staff were usually familiar with the service and the people using it. Any new agency staff undertook a service induction to familiarise themselves with the service and people's needs. Staff received training to enable them to carry out their roles effectively. The service manager used a training matrix to monitor staff training. We noted that the initial matrix shown to us only included information that staff were booked for training but not if they completed it. Further exploration revealed that not all staff attended this training. We discussed this with the service manager, who addressed the issue. They provided us with an updated training matrix after the assessment site visit. The new document evidenced that all staff completed the required training. Staff received supervision; however, it has been less frequent in the last six months than the agreed by the provider timeframes. Additionally, not all staff members have completed their yearly appraisals. The service manager explained that this was due to the managerial changes in September 2023. However, since January 2024, the service manager and the new deputy manager have been working on increasing the frequency of supervisions and completing all staff appraisals.

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.

During our assessment we found that medicines were not always recorded or monitored safely. This resulted in a breach of Regulation 12 (1) (2) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We identified issues with how medicines were stored. The room and the fridge temperatures 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. Medicines stock checks did not take place as stated in the provider's policy. The policy required that staff count all medicines once a week to ensure the correct stock level. However, weekly checks did not happen, and there were, at times, three weeks gaps between each check. When the medicines count happened, they showed continuous discrepancies between medicines in stock and records of medicines administered. This was the case at medicines check audits conducted by the service in November, December 2023, and January 2024 and during the check completed by an inspector during our onsite assessment visit. Therefore, we could not say that the staff always administered medicines to people as required. The service did not ensure that only authorised staff had access to medicines storage. During our visit, we observed an unauthorised person accessing one medicine cabinet. Staff told us this was an agreed practice for this person. However, this meant the person had access to all people's medicines, which was an unsafe practice. The provider conducted medicines audits in October 2023. These audits included some recommendations, including regular fridge temperature checks. However, these recommendations were still not followed at the time of our visit in January 2024. Furthermore, the audits did not identify all the issues highlighted by us during our assessment visit. Therefore, we assessed they were not fully effective.