Townsend Manor

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• 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

We identified a breach of regulation in relation to good governance. There was a lack of equipment and that service safety checks were out of date and broken equipment had not been repaired in a timely manner. The provider was not timely in providing equipment and staff had purchased items themselves including basic food items of bread and milk especially at the weekends. Staff were complimentary about the support of the manager who they felt listened to them. The staff say they work well as a team but lack support from the provider. There had been a lack of resident and staff meetings. Staff did not feel able to speak up with the provider as they felt they wouldn’t be listened to. There was a lack of detail on the improvement plan as it did not show who is responsible and a time frame for completion. There was a lack of audits. Information is sent to head office and not returned so we were unable to establish if any analysis, lessons learnt had been established and how they were to implement an action plan to make changes and improvements to the service. There was a lack of oversight by the provider due to the fact that regular visits to the service did not take place to allow them to observe and monitor the quality 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.

Several staff members told us they had raised concerns with the management team about the staffing levels and they had not been listened to and continuously told there were enough staff. One staff member told us they could raise concerns in staff meetings, however, they felt nothing changed. The majority of staff were complimentary about the manager in the service who they felt listened to them. However, they told us about the difficulties they had had in obtaining equipment. A staff member 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 on the floor to protect people.” A staff member told us how the staff worked well as a team and the manager was supportive, but felt morale was low due to the lack of support by the provider and said, “[Manager] does [their] best, but anyone higher, it feels like no one cares.” They told us they had not seen any provider representative in the service and the regional manager had only attended 1 staff meeting. Although they did attend the service on our second assessment visit.

The provider did not have a robust procedure where people and staff felt safe and secure to raise issues. Staff told us they felt speaking up about their concerns were a, “Waste of time,” “You can be seen as a touble maker,” and, “Like banging your head against a brick wall.” Where nothing gets changed and improvements are not made.

There was no registered manager in post at the time of this assessment. The manager was however in the processing of submitting an application. A relative we spoke with said, “[Name] is very approachable, we can always talk to them or the deputy, I don’t think the manager gets much support from head office, the area manager comes and then just swans off, it makes no difference. But we are happy with the manager.” Another relative told us, “The manager is very approachable and communicates well.”

Processes were not in place for ensuring the manager had support to fully comply with their role. The provider was not fully monitoring the service to ensure improvements were being made. There was a lack of support for the manager as regular visits to the service did not take place by the provider. This would allow them to observe and monitor the service and ensure good outcomes for people living there.

The manager told us they had an open-door policy, and they were trying to encourage staff to speak openly about their concerns in the service. Staff told us they were aware of the whistleblowing procedures in place and understood when to report concerns. Staff were complimentary about the support of the manager who they felt listened to them. The staff say they work well as a team but lack support from the provider.

There was a Duty of Candour policy and procedure in place. There were policies and procedures in place relating to freedom to speak up and whistle-blowing, which explained staff and provider responsibilities.

There was a lack of one-to-one supervision meetings for staff to provide them with a forum to raise any concerns about the service. This would give the management team the opportunity to explore if there were any concerns relating to equality and diversity in the staff team. The manager told us they had a plan in place to provide these going forward.

There were policies and procedures in place for equality and diversity.

At the time of our assessment the staff told us there were not enough working electronic handheld devices within the service. These devices hold information about the care each person requires to meet their needs and allow staff to record the actions they had taken to meet people’s needs. Staff confirmed as a result things did not always get documented, and records not updated. There was also a problem with Wi-Fi as there was a poor signal in parts of the home. The manager confirmed that handheld devices were not always working effectively and as they were shared by staff, information is inputted on their colleague’s behalf. This system does not ensure the accuracy of information recorded by a third party. There was a lack of equipment and service safety checks were out of date and broken equipment had not been repaired in a timely manner. The provider was not timely in providing equipment and staff had purchased items themselves including basic food items of bread and milk especially at the weekends.

The provider's governance processes were not robust. We found a number of concerns with their oversight of care planning, risk assessments, health monitoring charts, staff supervision, engagement with people, relatives, and staff. These concerns had not been identified and addressed by the provider's internal governance processes. Therefore, the system did not support the manager and provider to analyse, learn lessons, implement an action plan and put measures in place to reduce future risks. However, audits that had been undertaken did not always include a timescale for completion and who was responsible for the improvements. This was also the case for the slips and trips audits of people using the service. There was a lack of oversight by the provider due to the fact that regular visits to the service did not take place to allow them to observe and monitor the quality of the service.

Staff were able to demonstrate how they had involved other professionals in people's care including health referrals, care reviews and multi-disciplinary team meetings with other health professionals.

The manager told us they were engaging with the local authority and other health and social care professionals to address concerns and demonstrate how improvements were being made.

Health and social care professionals told us they were involved with the service and provided input into people's care and support, giving feedback and recommendations to staff to support their understanding of people's individual needs.

The provider had processes in place to seek support from other health professionals and work in partnership to improve people's care.

The manager told us they could check response times for the call bells from their office, but this was not formalised to ensure any shortfalls could be identified and measures put in place to address them. Where concerns were raised, actions had not always been taken promptly to ensure those raising concerns were fully involved in discussing what improvements had been made and evaluating whether these improvements were working effectively. The manager had introduced a handover book to enable information to be passed on to the relevant people or health professionals. The Local Authority carried out a quality audit and the manager was given an action plan to address the concerns identified, which they were working through.

The provider's processes were not always effective in driving continuous improvements and learning. For example, there was no formal or recorded audit taken of call bell response times, without this the manager could not be assured that staff responded to people’s requests for assistance promptly.