Townsend Manor

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 requires improvement. At this assessment the rating has remained the same. This meant some aspects of the service were not always safe and there was limited assurance around safety. There was an increased risk that people could be harmed.

The service was in a continued breach of legal regulation in relation to people’s safe care and treatment and staffing. We also identified a new breach of legal regulation to premises and equipment.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety as lessons were not always learnt to continually identify and embed good practice. Whilst the providers action plan in response to the previous CQC assessment set out what improvements would be made and by when; during this assessment we found continued breaches and new breaches of regulation. This was due to a lack of learning from the previous assessment and poor organisational oversight. This included a failure to embed and sustain actions in response to breaches of regulation found at the previous assessment.

Accidents, incidents, complaints and safeguarding were documented. However, the level of detail in which these records were completed was varied. This included what actions were taken to reduce the risk following incidents, what organisational oversight there was to monitor patterns and trends, and drive forward improvements. We also found occasions where staff had failed to escalate concerns to the registered manager and or senior management team in a timely way. This included staff not informing the senior management team of the fire-safety risk of a person who had started locking their door and did not always open their door on request of staff. This did not always demonstrate to us an embedded positive learning culture.

Leaders and the staff team worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

During this assessment we held a virtual meeting with the providers senior leadership team. They told us the improvements they would put in place following our concerns. This included more detailed and consistent documentation around people’s health conditions and known risks to guide staff.

Staff contacted professionals such as GP’s, district nurses, speech and language therapists and the mental health crisis team when people needed specialist advice and support. This advice given from professionals helped guide staff on how people should be supported and monitored to ensure their well-being. A relative confirmed to us, “The GP comes in each week, they have a JET team (joint emergency team) who goes in if there is a problem.”

Leaders worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. However, following a review of incident records, it became apparent that there was a misunderstanding of what constituted a safeguarding allegation and reportable incident. For example, incidents of alleged harm including, but not limited to, person-on-person altercations and or agitated behaviour that escalated towards other people. Records on occasion described these as a ‘behaviour’ rather than a safeguarding concern. The audit trail within these records sometimes lacked information, as it was not always clear as to when and where these incidents were reported externally. This included reporting to the CQC.

Leaders and the staff team had requested legal authorisations, such as Deprivation of Liberty Safeguards, for people who were assessed to lack mental capacity. Decisions around these were made in people’s best interests and for their safety.

The provider and staff team did not always work well with people to understand and manage their known risks. Care was not always provided to meet people’s needs that was safe and supportive.

Whilst we found no evidence that people had come to harm, we identified a continued increased risk of harm to people’s well-being. Staff did not always complete required safety checks or follow risk assessments, including for a person at high risk of self‑harm, where identified hazards were left unaddressed for several hours. Record‑keeping around pressure care and wound management was often inaccurate or out of date, leading to delays in referrals and increasing the risk of skin deterioration. Equipment such as specialist mattresses was set incorrectly, and weight‑monitoring records for people at risk of malnutrition were unreliable.

Repositioning schedules were not consistently followed or promptly updated after professional advice, and one person on a modified diet was offered unsuitable food. Staff also failed to escalate a developing fire‑safety risk when a person began locking their door, meaning evacuation plans were not updated in a timely way. Although leaders acted quickly when concerns were raised, much of the improvement was reactive rather than proactively identified. Despite these issues, most people and relatives reported feeling generally safe, with some expressing isolated concerns.

Whilst systems were in place to make sure that equipment, and utilities safety checks took place. Leaders and staff at the service did not always detect and control potential risks in the care environment. Fire-safety was not fully embedded into the governance monitoring systems of the service.

Senior managers were unable to provide timely evidence that all staff had participated in recent fire drills, and staff demonstrated inconsistent understanding of fire‑safety procedures. Inspectors observed a fire door propped open with a novelty doorstop, preventing it from functioning correctly. The last recorded fire drill, in June 2025, was documented as a poor result, with staff not following required protocols. Attendance records were incomplete, preventing assurance that all staff had taken part. These concerns led to a referral to Cambridgeshire Fire Service, and immediate improvements were made during the assessment.

We also found environmental safety issues. Doors to areas containing hazardous items, such as sluice rooms, areas storing disinfectant and lockable cupboards, were found left open, allowing access to chemicals and equipment. Heavy furniture, including wardrobes, had not been risk assessed for people who may display behaviours that could escalate. Shared spaces, including the sunroom and quiet lounge/prayer room, were being used for storage due to limited available space, reducing the appropriateness of these areas for people’s use.

We also found a damaged flooring join in a shared lounge that posed a potential trip hazard for people at risk of falls. Feedback from people and relatives about the environment was mixed: some described the premises positively, while others felt the standard did not reflect the advertised “five‑star luxury” image and that certain areas required attention.

The provider did not always make sure there were enough qualified, skilled and experienced staff. The assessment identified ongoing issues with staff fire‑safety training. Due to 2 training systems operating simultaneously, senior managers were unable to demonstrate quickly that all staff had completed up‑to‑date fire‑safety training or attended a fire drill in 2025. One staff member reported never receiving fire training despite several years in post. Although fire‑safety training was requested in May 2025, it was only prioritised after concerns were raised during the assessment, despite a previous fire incident at the service. Additional training was arranged promptly once highlighted, but it is too early to confirm that this has been embedded.

Staffing levels remained a concern. Observations showed periods where staff were not present due to supporting other areas of the home, leaving people unsupervised and anxious. Staff reliance on sensor alerts increased during these periods. Following CQC feedback, managers introduced a night‑time zoning plan with additional night staff and a twilight shift.

Service users, relatives and staff gave mixed views about staffing levels. Several reported that staffing was insufficient, particularly during the day, at night and at weekends, sometimes leading to delays in people receiving support. Some staff felt shortages resulted in unintentional neglect, while others felt staffing was generally adequate depending on the unit. While leaders responded positively to feedback and took steps to increase staffing, the assessment concluded that improvements were reactive and may not have occurred without CQC intervention.

Recruitment processes were safe, with appropriate pre-employment checks such as references, identity verification and DBS checks. Staff generally received supervision, although not consistently, with one staff member unable to recall their last session. The registered manager planned to offer staff further development opportunities.

Leaders and the staff team assessed and managed the risk of infection. They detected and controlled the risk of it spreading. A relative confirmed, “Yes, it is incredible how clean they manage to keep it’s immaculate.”

However, due to some people’s complex behaviours we did observe incidents where areas of the home had very strong smells that did not dissipate. The senior management team told us that areas of the flooring in the service, where the strong smell did not improve even after cleaning, were going to be replaced. During this assessment we saw some bedroom floors replaced to help promote people’s dignity and good infection control practices. However, areas such as some shared corridors where there had been toileting accidents on the floors, had not yet been replaced. A relative told us, “Mostly, we have had issues of the bathroom stinking of wee and the crash mats get dirty but, on the whole (cleanliness), it is pretty good.” Another relative when asked if they felt the service was clean replied, “Yes definitely, apart for the dishwashers that were in the kitchenette. They broke down and haven’t been working for over a year and now they have been removed.”

The service did not makealwayssure that medicines and treatments were safe and met people’s needs,capacitiesand preferences.

EMAR (electronic medication administration record) reviews showed medicines were given as prescribed, and topical patch applications were recorded, though some entries were completed retrospectively. Allergies were not consistently documented on eMARs, and this had not been identified during recent medicines audits.

Self‑administration was supported, but one risk assessment was completed only after the person had already been managing their own medicines. Best‑interests processes were followed for covert administration, with pharmaceutical guidance in place to ensure safe practice.

Care plans varied in quality. Some were detailed and person‑centred, while others lacked essential clinical information. Key gaps included missing blood glucose parameters in diabetes plans, lack of seizure guidance in epilepsy plans, and insufficient information about monitoring requirements for people on high‑risk medicines such as anticoagulants. PRN (as required medicines such as pain relief) protocols were not always person‑centred and did not consistently reference pain‑assessment tools for people unable to communicate, creating risks around inadequate pain relief.

Staff knew how to report medicines incidents, with evidence of investigations and follow‑up actions. All staff had completed medicines training and competency checks. However, monthly medicines audits had not identified the issues found during the inspection, indicating that governance systems were not consistently effective in recognising and addressing risks.

We found medicines, including controlled drugs, were generally stored and administered safely. Staff were kind, understood the importance of time‑critical medicines, and completed additional monitoring where needed.