Townsend Hub

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection this key question was rated requires improvement. At this inspection this key questions remains the same. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

At our last inspection the provider was in breach of regulations in relation to governance and records. During this inspection not enough improvement had been made and the provider remained in breach of legal regulation in relation to the governance of the service.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. People and staff described a positive culture within the service. Staff told us they felt supported and that issues were addressed quickly. One staff member said, “Since the new manager took over, it’s gone a million times better – very supportive and approachable.”

Despite leaders understanding 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. Leadership was visible and approachable, but some staff and relatives told us communication could be better. Staff told us they could raise concerns, but some felt there was too much paperwork and not enough support for wellbeing. While managers were committed to improving the service, staffing pressures and gaps in care planning show leadership was not consistently effective in driving improvement.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt able to raise concerns and that managers listened. One staff member said, “The manager is approachable and listens.” There were regular meetings where staff could share feedback, and issues raised were acted on promptly. This helped maintain an open and supportive environment.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider promoted equality and diversity. Staff had completed training in equality, diversity and inclusion, and we saw examples of culturally sensitive care.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. Systems of oversight were not completely effective. Some audits failed to identify key gaps in care plans, such as missing Waterlow scores and unclear catheter monitoring instructions. Documentation around consent and capacity was incomplete. Falls mitigation plans were generic and not person-centred, despite repeated incidents. We raised these concerns with the provider during the inspection, began to take action to address these shortfalls and has updated us with their progress.

The provider 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. The provider worked closely with other health and social care professionals to ensure information was shared and escalated when needed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider did not always demonstrate effective learning and improvement. While there were examples of positive practice recorded repeated concerns about care planning, risk management and audit failures show that lessons were not consistently embedded since the last inspection.