Townsend Manor

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in a continued breach of legal regulation in relation to governance at the service.

This service scored 36 (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 provide the support staff needed to work towards a culture of equity, equality and human rights, diversity and inclusion that fully understood the challenges and needs of people using the service. The lack of effective organisational and leadership oversight at the service meant that there was not always enough staff to always support people’s individual needs appropriately or engage with them in a meaningful way. A relative said, “There isn’t enough staff, on occasions it would be nice to see at least one more member of staff depending on the needs of the people on the unit. If someone needs two carers who helps the rest of the residents?”. Whilst people's main care needs were being met, their quality of life and experiences within the service were poor as staff did not have sufficient time to meaningfully engage with them other than delivering task-based care.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

Whilst there was positive feedback about visibility and responses of the onsite senior leadership team, there was also feedback which showed people were not always assured by the providers oversight and level of support on a day-to-day basis “We know the manager, and the home is well managed by her. We feel the Head Office doesn’t give her the support she needs, we have dealt with them.” And “They do as well as they can possibly manage with the limited resources they have. The manager is wonderful; she goes above and beyond.”

The service had multiple repeated breaches in regulation and new breaches found during this assessment. At our last assessment we found the provider was not fully monitoring the service to ensure improvements were being made and at this assessment we found improvements had not been made in this area. This demonstrated a problem with the governance and oversight of the service which had not been addressed effectively by the provider.

People did not always feel they could speak up and that their voice would be heard. Staff and people’s relatives had mixed opinions on whether the provider listened to them. Surveys were available for people and their representatives to complete to feedback on the service provided. There were also staff meetings and relatives’ meetings held to discuss and update what was going on at the service. Relatives told us, “Oh yes you can express your views, as I am there quite a lot it makes me wonder what happens with some who haven’t got that voice.” And, “Yes, I have been to relatives meeting but some of the issues have to be sent up to [head office] and sometimes the issues aren’t resolved after the meeting, but it is not the manager’s fault.”

Even though the service had a “Raising concern, freedom to speak up and whistleblowing policy” and procedure in place some staff told us they felt they were not always listened to and respected by the provider. A staff member said, “[We] have staff meetings, not worth adding to the agenda as it doesn’t get done…[for example] have raised staffing levels.”

The service had a diverse workforce in place, and no concerns were directly raised around diversity concerns. We reviewed incident records where racist language was used towards staff. When we asked managers how they supported staff after such incidents, they told us they offered debriefs and an open-door policy to support staff.

Staff in the main told us they were supported by the registered manager. A staff member said, “[Named manager] works hard, will do any job needed. Residents come first; staff are a very close second.” However, another staff member described the staff culture at the service as, “cliquey.”

The provider had governance systems to monitor and improve quality; however, these were not effective. For example, quality monitoring and audits took place, but these were not robust enough as serious concerns were identified during this assessment. Furthermore, where the provider’s governance checks did identify shortfalls, action was not always taken to ensure improvements were made, embedded and sustained.

During this assessment we found people’s care plans and risk assessments were not always accurate. Monitoring of the service had not identified significant shortfalls such as staff not always following people’s care plans around the safe and effective management of self-harm and safe wound management. The senior management team could not easily confirm all staff had up to date fire-safety training or had attended recent practice fire drills. The monitoring of the environment of the service had not identified that there were areas of the service with embedded strong odours that did not dissipate. Nor had audits identified that there were not enough staff to effectively meet people’s complex health needs including mental health support and escalating anxieties.

We found increased risk of harm was present for people due to insufficient detail in audits, and actions were not always monitored and followed up effectively. Examples around this evidence were fed back during this assessment and the senior management team responded positively to this feedback.

Although senior manager responded positively to feedback, we were not assured that these would have been identified independently without the CQC assessment. The repeated breaches in regulations showed the service had a history of where appropriate measures were not actioned and embedded effectively to improve the quality of the service.

Leaders and the staff team understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Referrals had been made to external health and social care professionals when specialist services and guidance was required to promote people’s well-being. However, not all advice and guidance given by external health professionals was responded to by staff in a timely way.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, and effective practice. However, prior to this assessment not all improvement actions required were identified, clearly recorded and acted upon to ensure these improvements were embedded and sustained.