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

We dentified 2 breaches of regulation in relation to safe care and treatment and staffing. People did not always have the required equipment to meet their needs. We identified some risks during our first site visit, and some had not been fully addressed by our second visit and potentially put people at risk of injury. People did not always have risk assessment in place for such areas as skin integrity, diabetes and the use of bed rails. Those that were in place were not personalised or have detailed actions to mitigate those risk identified. We found that records did not always show if actions had been taken in line with the care plan, for example, where a person requires regular turning. People were being placed at risk as safety checks had not been carried out for example, legionella and portable appliance testing had not taken place. The manager failed to send us requested information around risks and safety equipment. Staff did not all have the required training to ensure they had the required skills to support people’s needs. Fire training had not been carried out for all staff, although a recent false alarm demonstrated that staff knew the action to take. We did not receive the requested information about fire safety checks and drills. Whilst a dependency tool was being used, we found that staffing levels did not meet the needs of people and the layout of the building was not considered. Over a quarter of care staff were being covered by agency staff and their records did not provide detailed information of their training and when it was completed. This put people at risk. The service was visibly clean, and staff confirmed they had the required equipment available for maintaining good infection control practices. There were systems in place to record, monitor and learn from falls.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives had mixed views on the care provided by staff. Comments included "There is a constant turnover of staff." "The staff seem OK and know what to do."

There were gaps in the training records which showed staff did not always have the skills to meet people's needs.

We were not assured that there were effective systems and audits in place to learn lessons, in relation to staffing levels and safeguarding. However, falls meetings were held, including review undertaken of who had assistive technology and they review the times of falls and where they had taken place. Audits were also undertaken following a fall and the manager reviewed each person’s records and provided further guidance to staff, such as checking that referrals were made to the frailty clinic and risk assessments updated.

People were complimentary about the care they received. A person told us they had visited the service before they decided to move in and were involved in discussing what they expected from the service.

People’s daily notes included red flag incidents, which demonstrated for example if a pressure ulcer was developing or a fall had happened, actions taken by the staff and follow up actions required.

People’s records demonstrated they were supported to see health professionals when required.

The GP provided regular visits to the service and that regular reviews were held for those people with long term conditions.

People and their relatives we spoke with told us they felt safe living at the service. Comments included, "I feel very safe here." "[Family member] is very safe with [Staff]."

Staffing was having an impact on people’s safety as there were not always staff available in the communal areas.

There were numerous items around the service which posed a risk to people. This included unsecured ornaments, many very heavy and free-standing fire extinguisher holders. All of these could be accessed by people and could cause them harm, if for example if thrown or pulled onto a person. In addition, the fire extinguishers in the stand-alone holders could be moved and therefore not available in the case of a fire. We saw an incident report and ABC form in May 2024 where a person had smashed 2 items on the floor.

There were gaps in the training records, which showed all staff had not undertaken safeguarding training. However safeguarding information was posted around the home and staff we spoke with understood their roles and responsibilities.

People and relatives we spoke with told us that risks has been identified and action taken. One relative said, “[Family member] has had a few little tumbles out of bed but they have put mats on the floor and a buzzer thing so I think [family member] is safe enough.” another relative told us, “[Family member] had a fall 3 weeks ago… they have put a commode, crash mats and alarms in [family member’s] room and lowered the bed and [family member] has a pressure mattress on the bed and a hoist, so that’s all okay.”

People’s care records held risk assessments in some areas, however, they were not in place for all risks associated with the person’s care. A staff member told us they had not received updated fire safety training and another staff member told us they had not received fire training at the service, but a senior had explained the process. Another staff member told us fire safety training was being rolled out. There had not been a recent fire drill but these were being planned. A recent false alarm had demonstrated staff knew what actions to take.

People did not always have risk assessment in place for such areas as skin integrity, diabetes, the use of bed rails such as risk of pressure ulcers, malnutrition, diabetes, self-harm, depression. Some risk assessments, such as falls were generic tick boxes, not personalised to the person’s specific risks and there were no control measures to guide staff. Those that were in place were not personalised or have detailed actions to mitigate those risks identified.

We found that records did not always show if actions had been taken in line with the care plan, for example, where a person required regular turning. This was particularly important due to the high levels of agency staff used.

People we spoke with told us that the service was clean. Comments included, “It always seems alright to me, it’s always clean." “It’s all very clean and tidy, very much so, I can’t fault that."

On our first visit, there were only 2 domestic staff on duty to clean the whole building. A staff member told us sometimes there was only 1 domestic staff working at weekends. Deep cleaning for individual rooms was undertaken on the day of the month for the ‘resident of the day.’ This was confirmed in the records.

People were being placed at risk, as safety checks had not been carried out for example, for legionella and portable appliance testing. The manager failed to send us requested information around risks and safety equipment. We also found that doors were unlocked to the sluice room, the room that held cleaning materials and the door at the top of the stairs and all of these areas were accessible to people which could have put people at risk of serious injury. However, the service was visibly clean, and staff confirmed they had the required equipment available for maintaining good infection control practices. Although the service is newly built and there were some issues with leaks and limited storage. The environment lacked signage to help people living with dementia find their way around.

The processes in place were not effective, equipment is not serviced or purchased in a timely way. The manager confirmed that a hoist had broken and was not available for 11 days. The hoist servicing had not been carried out and was out of date due to the non payment of bills. This was resolved during the assessment. Staff told us there had been a delay in the provider supplying required equipment, which meant staff had purchased items themselves, such as locks for the bin storage. Staff told us about the difficulties they had in obtaining equipment. One member of staff said, “There are issues with equipment. If we order an air mattress it takes days before it arrives. There are insufficient crash mats, we have to use spare mattresses to put on the floor to protect people.”

People and relatives we spoke with had mixed views about staffing. Comments included, “There is a constant turnover of staff, [manager] says there is the same number on at weekends but I don’t see anyone about at weekends and I do through the week.” “You have to look for someone sometimes… there is a core of great staff, then lots of agency.” “The staffing numbers can be a bit variable, especially at weekends, there doesn’t seem many staff at weekends.” and “Well they keep changing the staff don’t they, never the same ones twice."

A staff member told us how they had raised concerns about staffing levels, but no changes were being made by the provider. The staff were not assured the numbers of staff needed were in line with the needs of the people using the service. Another staff member told us they had, “101 jobs to do but no time to do them.” They shared an example of when they had asked a person if they would like a shower and the person responded they did but had not liked to ask as they knew they were short of staff. Another staff member told us, “I do not think there is enough staff on nights as they expect 1 carer to look after 10 [people] in a unit then also to look after 1 [person] who is upstairs on [their own] …can be agitated and can lash out.” They explained that this meant that they had to leave the unit with no staff and in addition there were people who walked with purpose on the unit. Another staff member said, “Sometimes I am the only person on the unit with 10 people… about 5 of them are relatively independent but the others are not, 2 people [need the support of 2 staff]. Sometimes the night staff help by doing some of the showers. I have to pop across to the other unit to ask for help for example with personal care. I sometimes make a start and then have to go and ask for help, however this means that there is no one for the other people or in the lounge.” Another staff member said, “Currently staffing is not good, it is going to get worse with the impact of the holidays. They do not take in account new admissions or levels of dependency.”

Staff were not always available in the shared areas to ensure people were safe, this was because they were busy supporting other people. We observed a person trying to hit another person with a shoe, when staff were busy supporting other people with their personal care needs. Although, staff did show up when they had heard the incident and prevent it from escalating further. However, if staff were present the potential incidents could have been prevented. We could see staff were very busy, supporting people with their task-based care needs, there was very little time spent with people to provide social interaction. Staff told us they felt they struggled with the staffing numbers, they did feel people received the care they required, but this was down to the commitment of the staff to work hard. A staff member told us that whilst people had their personal care needs met, they did not feel people received additional support and likened the work to supporting people on a “Conveyor belt.” They said people and relatives often complained to staff about the staffing levels, but it was out of their control to make any changes.

There was a dependency tool in place, the manager told us they sent a document including people’s dependency needs to the head office, who then told the manager how many staff hours were needed. However, the tool did not take into account the layout of the building, for example. Without further monitoring tools, such as call bell audits, the provider could not be assured the staffing levels were appropriate and met the needs of the people using the service. This was also due to the lack of regular visits to the service by the provider to allow them to observe and monitor the staffing levels. The manager told us they were facing difficulties with recruiting staff and in addition, another service had opened nearby which paid more to staff and therefore staff were starting to leave. Staff did not receive regular supervision and appraisals to support them in their learning and development. The training matrix showed significant shortfalls of staff completing training to support them to care for people safely. Staff did not all have the required training to ensure they had the required skills to support people’s needs. Fire training had not been carried out for all staff, although a recent false alarm demonstrated that staff knew the action to take. We did not receive the requested information about fire safety checks and drills. However, recruitment checks for registered nurses had not included a check with the National Medical Council to check the register. We were assured this had been undertaken on day two of our assessment visit.

People told us the service was clean and there were plenty of domestic staff to keep their rooms clean and tidy. One relative said, “It’s all very clean and tidy, very much so, I can’t fault that.”

Staff had personal protection equipment situated throughout the service giving them easy access to wear when needed.

We observed domestic staff working appropriately and adhering to infection prevention and control procedures. One staff member said, “I use personal protective equipment (PPE) when supporting people with their personal care.”

There were processes in place to ensure the service was kept clean and ensure that staff had access to personal protective equipment.

People and their relatives confirmed they received their medicine. One relative told us, “[Family member] gets all their medication, the staff go round with the trolley." We found medicines were stored safely and securely. Regular temperature checks were undertaken to ensure medicines were kept at a safe temperature. On the ground floor a record was maintained of expiry dates for medicines in stock. Medicine administration records (MAR) showed when people had received their prescribed medicines. Where gaps were found in the MAR charts, this had been followed up by senior staff and action taken.

Where people had medicines to be administered when needed (PRN), protocols were in place to guide staff when these should be considered. However, there were inconsistencies in the recording in the MAR charts, some entries were left blank, and some had the code for PRN offered but not needed. Staff responsible for administering medicines told us they were trained in the safe handling of medicines and had their competency checked. Records showed medicine competency checks had been undertaken in the last 12 months. During our second visit we saw a staff member undertaking a medicine competency with the newly employed clinical lead. A staff member told us medicines were dated when they were opened, however, we found from a sample of medicines stored in the trolley, this was not always the case.

Some improvements were needed to ensure that risk assessment were in place. People’s care records held risk assessments for self-administration. There were no risk assessments in people’s care records relating to the use of creams which may be flammable and where they had been prescribed anti-coagulant medicine. Records of medicines to be administered externally, such as creams, did not show they were always being administered as prescribed. We found one record which did not have a completed body map to show where on the body the cream was required. However, medication audits undertaken in March and May 2024 included action plans, the action plan identified actions were completed within the month of the audit.