- Care home
Townsend Manor
Assessment report published 20 April 2026
Contents
Ratings
Our view of the service
Date of assessment: 24 November 2025 to 05 February 2026. The service is a care home with nursing providing personal care, support, and treatment of disease, disorder or injury to people. Some of whom have a physical disability, sensory impairment, dementia and mental health support needs. Townsend Manor can accommodate up to 70 people. At the time of our assessment, 61 people lived at the service.
We undertook this assessment to follow up on the previous 3 breaches of regulation in relation to safe care and treatment, staffing, and good governance. At this assessment we continued to find significant concerns. Whilst the provider, registered manager and management team were keen to improve the service and took our feedback seriously; we could not be assured there had been reflective and positive learning from the previous CQC assessment. As such, there are 3 continued breaches of regulation in relation to safe care and treatment, staffing, and good governance. We also found a new breach of regulation in relation to premises and equipment and dignity and respect.
Whilst we found no evidence that people had come to harm, we identified a continued increased risk of harm to people’s well-being. This was in relation to the safe management of people’s known risks, including emerging new risks. People at a high risk of poor skin integrity were not being repositioned by staff in line with their risk assessments, thus increasing the risk of further skin deterioration. Specialist mattresses used to help promote good skin integrity, were set at the wrong settings. Governance systems in place to monitor the accuracy of records held and whether staff were following the guidance as set out in these records continued to be not effective nor robust. The improvements required found during this assessment had either not been identified by the service or had been identified but actions taken not fully embedded and sustained.
The senior management team were unable to quickly evidence that all staff had up to date training in fire-safety. Nor could they evidence that all staff had attended a recent fire drill practice. Fire drill practices help ensure knowledge and confidence in the event of an emergency such as a fire. As such, we made the fire service aware of our concerns.
Whilst we observed staff working hard, some people, relatives and staff told us there were shortages of staff. We observed occasions when there were not enough staff to meet people’s needs.
Staff treated people with kindness. However, we also observed some conversations held between staff in the presence of people that were not always dignified. We also saw some missed opportunities by staff to engage fully with people. People’s dignity and privacy was not always promoted and maintained by staff or the environment. Group activities took place and there was a bistro area that people could sit should they choose to do so and engage with other service users or visitors.
There was some misunderstanding within the management team about what constituted a safeguarding allegation and reportable incident. This improved during this assessment and notifications detailing some incidents, that the registered person was legally obliged to notify the CQC of, were received retrospectively.
Environmental improvements were required to promote people’s safety and maintain their dignity. During our site visits we found some doors and cupboards open that should be closed. This was so people did not have easy access to items such as chemicals and or gauzes. Certain areas of the building, including shared corridors, had a very strong smell of urine that did not dissipate or promote the people who lived there’s dignity. For a service where some people were living with dementia and or were sensory impaired, there was a lack of information, including daily menus and signage in line with the Accessible Information Standard.
People’s medicines were stored and administered safely. However, audits on safe medicines management had not identified that records did not always include enough information to guide staff.
There was a continuity of care when people moved between different services and staff worked with health professionals to promote people’s wellbeing. Whilst some external health and social care professionals expressed some mixed opinions about the service, we also received some positive feedback. This included how staff at the service had worked well with a health professional to help improve a person’s quality of life.
Systems and checks were in place to help recruit staff safely. People’s needs were assessed prior to admission. Consent and least restrictive practices were in place as required by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.
Staff had mixed opinions on whether they enjoyed their roles. In the main staff told us they had supervisions. There were opportunities for staff to develop their skills and knowledge, should they choose to do so. Leaders were visible within the service and led by example.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. In addition, we have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
Some people could not directly tell us about their experience. We used observations including short observational framework for inspection to help capture people’s experiences.
Whilst we found some significant shortfalls in relation to people’s records to guide staff, and monitoring of risk to people, people and relatives had mixed opinions about the service. People and their relatives told us staff tried to make them feel at home and were in the main kind and friendly towards them. Relatives said, “The good [staff] are really good, nice and caring, they just want to help and do care.” And, “I do think they are very kind.” However, another relative told us, “It depends who is on there, some need further training and to be more friendly and look as if they want to be there, they need to be people persons.” We observed some missed opportunities for staff to acknowledge and fully engage with people.
Visitors to the service were made very welcome. A relative told us, “This weekend as he is very ill, we have moved in for the weekend, and they have brought us food and drinks, and they have looked after us…Staying there it has opened our eyes to how lovely and caring they are and the constant caring relationship they have with [family member]. We can go 24/7 to see him.”
People had mixed opinions on the food offered but relatives told us they thought the food was good. A relative said, “He has a mixed opinion from what I see I think it looks very good.”
We observed different group activities on offer for people to take part in should they choose to do so. People and relatives had mixed opinions about whether there was enough staff to support them at the time the person wanted assistance. A relative told us, “Not really, no it has to be when someone is available.”
Staff sought people’s permission before assisting them. Staff respected people’s choice where possible. A relative told us, “She has her own choice as to when she gets up and goes to bed and what she wants to eat.” People’s privacy was promoted by staff; however, we found at times people’s dignity was not always maintained by the staff or the environment.
Relatives had mixed opinions around the layout of the service. A relative said, “I think that he would benefit from being on a different unit than the one he is on, the dementia unit. If he wants to sit in the lounge, he has no one to talk to and he still likes a conversation, which is why he goes to the bistro to get some interaction.” And, “As they have dementia units, they have locked doors and people in wheelchairs can’t reach them. My issue is with the ornaments…Sometimes it’s tricky to get around a coffee table with a huge vase. The quiet room is decorated in black and grey. In the dining room there isn’t much room to manoeuvre the wheelchairs.”