Archived: Gorton Parks Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to person centred care, safe care and treatment, meeting nutrition and hydration needs, and good governance. A collaborative assessment of people’s needs was not always completed. The provider did not always work with other services to ensure care and treatment remained safe. There was a failure to assess the nutritional needs of people living at the home and follow and implement relevant nationally recognised guidance.

This service scored 33 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

Although there had been some improvements to the overall content of assessments, there was no evidence, meaningful discussions had taken place with people or their families to ensure the information was accurate and reflective of their current needs. Assessments were often reviewed solely by nurses or senior staff, and as a result, did not consistently capture people’s voices or personal perspectives.

Assessments were recorded in the electronic care planning system. Within the “Care Information” section, we found records were not consistently accurate or up to date. For example, 1 person who had lived at the home for more than three years was still recorded as having a Statement of Intent and being on an End‑of‑Life Pathway, despite this information being over 3 years old.

Another person, identified as agitated and both physically and verbally aggressive, did not have any agreed or clearly defined strategies in place to support their behaviour. Instead, the assessment instructed staff to document incidents, attempt distraction, and, if unsuccessful, inform the nurse in charge so Lorazepam could be administered as a last resort. This did not provide staff with proactive, person‑centred approaches or a structured plan to support each person safely.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

The risk of malnutrition and dehydration were monitored using evidenced based tools. However, each tool was not used to its full capacity which meant needs were not always met in line with current guidance.

One person was at high risk of malnutrition and had lost a total of 5kg over the previous three months. They were on nutrition and hydration monitoring, and according to their nutritional care plan, should have been weighed weekly. However, weight records showed they had only been weighed on three occasions within a two‑month period.

Another person, who had a diagnosis of type 2 diabetes, was at medium risk of malnutrition and dehydration and required a pureed diet. Although their weight remained within an acceptable range, records showed they had been given sausage, bacon and beans for breakfast on 45 occasions in the two months prior to the inspection. The provider had not recognised processed meats can contribute to insulin resistance, nor had they considered, pureed‑diet guidance advises avoiding gristly meats and sausages. This person lacked capacity to make dietary decisions, yet there was no evidence that staff had considered whether the meals provided were appropriate or aligned with their assessed needs.

There was no evidence, when people did not eat well at mealtimes, they were offered additional snacks or smaller, more frequent portions between meals to help maintain their weight.

We received mixed feedback about the food served. Comments included, “I find the food okay. There are a couple of choices. Sometimes the menu is a bit ‘samey’.”; “The food is passable.” and “[Name] refuses a lot of the good. Says its all the same. [Relation] visits every day and he brings in food pretty much every day.”

The provider did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

We received mixed feedback about how the provider worked with other services, and we found there had been delays in ensuring people received medical care and support when they needed it. The provider had identified previous incidents where staff did not obtain prompt medical intervention for people who were becoming acutely unwell, and disciplinary action had been taken. However, during the inspection we raised further concerns about a person who was deteriorating and did not receive a timely response from staff.

People were reviewed weekly by a GP; however, we found there was miscommunication and frequent discrepancies in the medical advice recorded. It was unclear where accountability lay, as staff appeared to have differing accounts of what had been agreed.

When people were sent to hospital as an emergency, relevant information was sent with them.

The provider did not support people to manage their health and wellbeing, so people could not maximise their independence, choice and control. Staff did not support people to live healthier lives, or where possible, reduce their future needs for care and support.

People were not regularly supported to see a dentist or have their oral hygiene assessed. We received several comments from relatives regarding the poor condition of their relations oral hygiene. A staff member told us, “Oral care is completed (once daily). With oral hygiene, most need help. We try our best in the morning to complete this, but it depends on their mood.”

We could not find evidence people received regular podiatry treatment. Several people had noticeably overgrown toenails. Podiatry visits recorded at times that were unlikely to be accurate, including entries made for 6.30am. Some staff told us they cut people’s toenails themselves; however, this practice placed people with poor circulation or diabetes at risk, as they required specialist podiatric care to prevent injury and infection. Staff gave varied feedback on when podiatrists visited the home including, weekly, monthly and 6 monthly.

People were still unable to access the garden area and fresh air when they wished, despite this concern being raised at the previous inspection. Access to outdoor space is an important part of maintaining physical and emotional wellbeing, yet people remained dependent on staff availability to support them outside. This limited their opportunities for fresh air, natural light and meaningful activity, and did not promote a healthy or stimulating environment. One person told us, “We play dominoes as you have seen and that’s about my limit. I do want to go out more and it gets to me, staying in all the time. They did take me to Tesco for some new trousers last week but at [age given], I feel I’m still okay. I should have more chance to get out.”

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

The provider did not have effective systems to monitor people’s health, wellbeing or the effectiveness of the care being delivered. We found repeated gaps in oversight, including missed weight monitoring for people at risk of malnutrition, unclear or inaccurate podiatry records, and a lack of action when people were not eating well. There was also limited evidence that concerns identified at previous inspections, such as restricted access to fresh air, had been reviewed or addressed.

The provider had developed a nutrition improvement plan which included increased fluid‑target checks, separate mouth‑care improvement actions, and guidance for nutritional supplements to be given two hours either side of mealtimes. Although this plan had been implemented two months before the inspection, we found no evidence it was being followed in practice. Staff were not consistently completing the required checks or delivering care in line with the plan, meaning the intended improvements to people’s hydration and nutritional outcomes were not being achieved.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff understood the need to obtain verbal consent from people; however, in practice they did not recognise the importance of securing and recording valid written consent. We found instances where staff had signed electronic care plans on behalf of people without having the legal authority to do so. This meant the service could not demonstrate, consent to care and treatment had been lawfully obtained or appropriately documented.