Townsend Manor

“Whilst we found no evidence that people had come to harm, we identified a continued increased risk of harm to people’s well-being. This was in relation to the safe management of people’s known risks, including emerging new risks. People at a high risk of poor skin integrity were not being repositioned by staff in line with their risk assessments, thus increasing the risk of further skin deterioration. Specialist mattresses used to help promote good skin integrity, were set at the wrong settings. Governance systems in place to monitor the accuracy of records held and whether staff were following the guidance as set out in these records continued to be not effective nor robust. The improvements required found during this assessment had either not been identified by the service or had been identified but actions taken not fully embedded and sustained.”

“The senior management team were unable to quickly evidence that all staff had up to date training in fire-safety. Nor could they evidence that all staff had attended a recent fire drill practice. Fire drill practices help ensure knowledge and confidence in the event of an emergency such as a fire. As such, we made the fire service aware of our concerns.”

“Whilst we observed staff working hard, some people, relatives and staff told us there were shortages of staff. We observed occasions when there were not enough staff to meet people’s needs.”

“Staff treated people with kindness. However, we also observed some conversations held between staff in the presence of people that were not always dignified. We also saw some missed opportunities by staff to engage fully with people. People’s dignity and privacy was not always promoted and maintained by staff or the environment. Group activities took place and there was a bistro area that people could sit should they choose to do so and engage with other service users or visitors.”

“There was some misunderstanding within the management team about what constituted a safeguarding allegation and reportable incident. This improved during this assessment and notifications detailing some incidents, that the registered person was legally obliged to notify the CQC of, were received retrospectively.”

“Environmental improvements were required to promote people’s safety and maintain their dignity. During our site visits we found some doors and cupboards open that should be closed. This was so people did not have easy access to items such as chemicals and or gauzes. Certain areas of the building, including shared corridors, had a very strong smell of urine that did not dissipate or promote the people who lived there’s dignity. For a service where some people were living with dementia and or were sensory impaired, there was a lack of information, including daily menus and signage in line with the Accessible Information Standard.”

“People’s medicines…”