Archived: Gorton Parks Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people’s needs were not always met.

The service was in breach of legal regulation in relation to person centred care and good governance. People did not receive care and treatment which was personalised specifically for them. The provider had not identified information in care records was not up to date.

This service scored 32 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People did not always receive care and support when they needed it. For example, we observed one person consumed only a few mouthfuls of soup and was given a cup of tea in a white mug. For dessert, they were provided with fruit and cream. The cup of tea was not drunk. However, documentation for this lunch was not completed until 18:50 in the evening and did not reflect our observations. Staff recorded that the individual ate soup, sandwiches and ice cream, which was inconsistent with what we saw. A staff member told us, “It is so hard to complete all of the documentation, there is a lot and it feels unmanageable. The documentation does not always match the job; this is because you need to take your time when support them (people).”

People were not consistently receiving essential care interventions, including regular repositioning to protect their skin integrity. This placed people at increased risk of pressure damage and demonstrated, staff were not following care plans or clinical guidance.

Food, drinks and snacks were not offered at appropriate intervals throughout the day. Although records stated that drinks were provided while people were in their rooms, our observations did not support this.

Several people were isolated and spent long periods alone in their bedrooms without meaningful interaction, engagement or monitoring. Opportunities to support people with their personal interests or preferred activities were extremely limited. People told us they had not been able to enjoy simple treats such as having their hair cut or their nails painted for a long time. This lack of stimulation and personal attention meant people were not supported to maintain their wellbeing, identity or sense of self. One person said, “I am very bored, I don’t do anything. I have not had my haircut for over a year. I eat my meals in my rooms. I go to the dining room every blue moon. The cleaners come in and clean my room but it’s the same each day.”

Bedrooms lacked personalisation. While some had been personalised by family, others were stark with no home comforts for people residing in them.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

We found several examples which demonstrated the provider had not fully understood or responded to people’s diverse and complex health needs. People with significant wounds, long‑term conditions and cognitive impairments experienced delays in receiving appropriate, coordinated care. This meant people were not supported to access timely specialist input when their health needs changed.

Following our inspection, the provider did make referrals to Tissue Viability Nurses (TVNs), diabetic review teams and other relevant professionals. However, there was no assurance that these concerns would have been identified by the provider’s own staff or through their governance systems without our intervention.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information for people was not readily available in alternative formats or presented in a way they could understand. This meant people were not always supported to make informed decisions about their care.

We found one person who was taking their medicine in a way that did not align with the prescribed instructions, and this was having a negative impact on their health. Although the provider told us the person had capacity to make this decision, the person had not been given any information about the risks or consequences of not taking their medication correctly. As a result, the person was unable to make a fully informed choice, and the provider had not met their responsibility in ensuring information was shared in a way to meet people’s communication needs in line with meeting the Accessible Information Standard guidance.

We observed a person being removed from the lounge and taken to the dining table without the staff member offering any explanation or reassurance. The person was not informed about what was happening or why they were being moved. This demonstrated a lack of respectful communication and did not support the person to feel involved, safe or in control of their care

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

People and their relatives told us they felt able to share feedback with the service. However, several relatives reported concerns they raised were not followed up or resolved. This included issues such as missing clothing and personal items. One relative told us they had informed staff, some of their family member’s jewellery had gone missing, but they had not received any update or explanation.

Some feedback was requested from relatives prior to our inspection and the uptake was low. The provider was obtaining further feedback as we closed the inspection process. A relative told us, “The manager I have spoken with is responsible and helpful. We did complain about the night staff but its ages ago and it got dealt with and the members of staff are no longer here."

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

The service did not always ensure equity in access for all people using the service. People with diverse communication needs, cognitive impairments or complex health conditions did not consistently receive information or support in formats they could understand, which limited their ability to make informed choices about their care. People did not always have timely access to specialist healthcare input or meaningful activities that reflected their preferences, backgrounds or interests. These shortfalls meant some people were disadvantaged in how they accessed care, support and opportunities within the service.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

People who were unable to communicate their needs were at risk of not receiving the care and support outlined in their care plans. This included people who were cared for in bed, who were particularly vulnerable to being isolated and overlooked. We observed staff were not consistently providing regular, meaningful interactions, which meant these people did not always receive the monitoring, reassurance or engagement they required. This placed people at increased risk of unmet needs, reduced wellbeing and potential neglect.

Although the environmental paintwork had been refreshed, all bedroom doors on Abbey Hey House were painted the same colour and had no names, symbols or signage to help people identify their own rooms. This lack of visual cues meant people, particularly those living with cognitive impairments, were not always able to orientate themselves to the correct bedroom.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Care records did not clearly identify how people could be supported to maintain or develop their independence. One person told us they hoped to return home and eventually work again, but this aspiration had not been explored or incorporated into their wider care planning.

End‑of‑life documentation was also limited and lacked clarity about people’s preferences and the support they would require. Several people had a “Statement of intent” recorded, indicating an expected death, despite this no longer being clinically relevant for many of them. People were not always involved in planning for their future care, including end‑of‑life decisions, as staff had recorded, people lacked capacity to participate. However, we saw, 1 person identified as Roman Catholic with specific spiritual beliefs, and these important aspects of their identity had not been considered within their end‑of‑life planning. This meant people’s wishes, values and cultural needs were not consistently reflected in their care.